Thursday, May 31, 2012

EKG Rhythm Strips 51

Identify the following rhythm strips.




Atrial fibrillation with unifocal PVCs

The rhythm is irregular with some PVCs.   The rate is 100/min.    No P waves are present.   Some fibrillatory activity is seen between the QRS complexes.   It looks like there might be P waves present before the 5th complex and following but this appears to be part of the ST segment.  If you look at the 1st complex you will see that following the T wave there is a slight depression followed by a slight positive rise.   This appears to be repeated in the complexes that follows giving the impression that a P wave is present.   The increase in the heart rate and shortening of the R-R interval would also give the impression that P waves are present.   Two unifocal PVCs are seen.  PR:  ---,  QRS:  .12 sec,  QT:  .38 sec.   The bottom tracing is an arterial blood pressure waveform.   You can seen the hemodynamic effects of the PVCs on the arterial pressure and pulse waveform.

Demand atrial pacing with multifocal PVCs

The rhythm is irregular due to the demand pacing.   The rate is 80/min.   Both sinus and atrial paced P waves are present.  The 5th and 6th complexes have sinus P waves.   Two multifocal PVCs are present.   The ventricles are completely paced.   PR:  .14 sec,  QRS:  .16 sec,  QT:  .44 sec.

Normal sinus rhythm with multifocal PVCs

The rhythm is irregular with a rate of 70/min.   The P waves are upright and have a corresponding QRS complex.   Two multifocal PVCs are present.   A compensatory pause follows the PVCs.  PR:  .20 sec,  QRS:  .08 sec,  QT:  .44 sec.

Sinus bradycardia

The rhythm is regular.   The rate is 43/min.   The P waves are uniform, upright, and associated with a QRS complex.   No ectopic beats are noted.  PR:  .16 sec,  QRS:  .08 sec,  QT:  .48 sec.

Sinus tachycardia with PACs

The rhythm is irregular with a rate of 132/min.   P waves are present and are paired with a QRS complex.  There are PACs that closely follow the 7th and 20th complexes.   The P wave of the PAC is hidden in the T wave of the previous complex.  Notice the change in the height of the T wave.  PR:  .16 sec,  QRS:  .16 sec,  QT:  .32 sec.

Reviewed 3/2/16

Wednesday, May 30, 2012

EKG Rhythm Strips 50

Identify the following rhythms.







Atrial flutter with variable ventricular response

The rhythm is irregular with a rate of 80/min.   Flutter waves are seen between the QRS complexes.   The ratio of flutter waves to QRS complexes varies.   No ectopic beats are identified.   PR:  ---,  QRS:  .16 sec,  QT:  .40 sec


Atrial fibrillation with slow ventricular response

The rhythm is irregular with a ventricular rate of 48/min.   P waves are absent but some fibrillation is noted between the QRS complexes.  No ectopic beats are seen.   PR:  ---,  QRS:  .12 sec,  QT:  .48 sec.

Atrial paced

The rhythm is regular with a rate of 60/min.   Atrial pacer spikes precede the very small P waves.  No ectopic beats are noted.  PR:  .20 sec,  QRS:  .08 sec,  QT:  .44 sec.

Junctional rhythm

The rhythm is regular.   The rate is 32/min.  The P waves are absent.   No ectopic beats are noted. The QRS complex is narrow.   PR:  ---,  QRs:  .08 sec,  QT:  .52 sec.

Normal sinus rhythm with ST elevation in the V1 lead

The rhythm is regular.   The ventricular rate is 65/min.   The P waves are upright, uniform, and are paired with a QRS complex.   No ectopic beats are noted.   There is a down slopping ST segment with an inverted T wave in lead II and a corresponding 3mm ST elevation in the V1 lead.  PR:  .12 sec,  QRS:  .16 sec,  QT:  .44 sec.

Reviewed 3/2/16

Tuesday, May 29, 2012

EKG Rhythm Strips 49

Identify the following rhythms.







Junctional tachycardia

The rhythm is slightly irregular with a rate of 102/min.  The P waves are inverted and precede the QRS complex.   No ectopic beats are noted.   PR:  .16 sec,  QRS:  .08 sec,  QT:  .40 sec.

Atrial fibrillation with rapid ventricular response

The rhythm is irregular.   The ventricular rate is 180/min.   No P waves are clearly seen.   There is some fibrillation noted between some of the complexes.    No ectopic beats are noted.  PR:  ---,  QRS:   .08 sec,  QT:  .26 sec.

Accelerated idioventricular rhythm

The rhythm is regular.   The rate is 72/min.   No P waves are seen.   No ectopic beats are noted.  The QRS complex is wide.   The T waves are tall.   A wide slow rhythm with tall T waves suggests hyperkalemia.   PR:  ---,  QRS:  .20 sec,  QT:  .72 sec.

1st degree AV block with unifocal PVCs and a couplet of PVCs

The rhythm is irregular due to the frequent ectopy.   P waves are present and upright.  The PR interval is prolonged.   Unifocal PVCs occur in singles and in a couplet.   PR:  .24 sec,  QRS:  16 sec,  QT:  .40 sec.

Sinus arrhythmia with 1st degree block

The rhythm is irregular.   The rate is 70/min.   Positive P waves are seen and they are associated with a QRS complex.   The PR interval is prolonged.  No ectopic beats are noted.  PR:  .22 sec,  QRS:  .12 sec,  QT:  .36 sec.

Reviewed 3/2/16

Monday, May 28, 2012

EKG Rhythm Strips 48

Identify the following rhythms



AV paced with biventricular pacing

The rhythm is regular with a rate of 75/min.   Both atrial and biventricular pacer spikes are seen before the P waves and the QRS complexes.   PR:  .20 sec,  QRS:  .16 sec,  QT:  .48 sec.

Atrial paced

The rhythm is regular.   The ventricular rate is 65/min.  An atrial pacing stimulus is seen before each P wave.  No ectopic beats are seen.  PR:  .20 sec,  QRS:  .08 sec,  QT:  .48 sec.

Atrial paced

The rhythm is regular.   The heart rate is 60/min.  Atrial pacer spikes are seen before the P waves. No ectopic beats are seen.  The ST segment is isoelectric but the T wave is inverted.  PR:  .20 sec, QRS:  .08 sec,  QT:  .44 sec.

Ventricular paced

The rhythm is regular with a ventricular rate of 68/min.  There are flutter/fibrillatory waves seen between the QRS complexes.   A ventricular pacing stimulus is seen before each QRS complex.  No ectopic beats are seen.   PR:  ---,  QRS:  ,16 sec.  QT:  .56 sec.

Ventricular paced

The rhythm is regular with a rate of 75/min.   The P waves are wide, split, and precede the QRS complex.  Wide P waves suggest left atrial enlargement.   No ectopic beats are seen.   PR:  .16 sec, QRS:  . 12 sec,  QT:  .40 sec.

Reviewed 3/2/16

Sunday, May 27, 2012

An Unusual AV Dissociation

At first glance this has the appearance of a 2nd degree type I AV block.   See if you can identify what is unusual about it.

In a 2nd degree type I AV block (Wenckebach) the PR interval gets progressively longer until there is a non conducted P wave or dropped QRS complex.   In most cases the P-P interval is regular.  Often the block occurs at the level of the AV node and has a narrow QRS complex.   The rhythm is usually benign and requires no immediate treatment 

In a 2nd degree type II block the conducted P waves have a consistent PR interval but there are some non-conducted P waves present.  The non conducted P waves may have a 2:1, 3:1 ratio.   The level of the block is around the bundle of HIS.   

With complete heart block the atria and ventricles each have an independent rhythm.   The P waves are not associated with the QRS complexes.  If the level of the block is higher in the His-purkenje system then the QRS complex will have a narrow appearance with a junctional escape mechanism.   A block below that level will have a wider complex with a ventricular escape mechanism 

In this strip, the rhythm has a Wenckebach-like pattern with progressive lengthening of the PR interval. The P waves are inverted suggesting a junctional focus. The QRS is widened. The negative QRS complexes in V1 suggest that this might be an existing left bundle branch block. There is not a dropped complex in this rhythm. Also notice that on the 2nd, 6th, 11th and 16th complexes there apprears to be a P wave in the ST segement of the QRS complex.

Unusual findings

Any comments?

Saturday, May 26, 2012

Megacode PEA Part 7

·         Assess for drug overdose
·         Assess for hx of drug use
·         Consult poison control

Tablets: Calcium Channel Blockers
·         Hypotension
·         Bradycardia with variable heart block
·         Altered mental status
·         EKG: slow rate, prolonged PRI, AV blocks
·         Rx Calcium chloride 10% 1-4G slow IV
·         Fluid resuscitation, vasopressor agents, atropine, transvenous pacing

Tablets: Beta blockers
·         Hypotension
·         Bradycardia with variable heart block
·         EKG: slow rate, prolonged PRI
·         Rx Glucagon 3-10mg IV bolus followed by infusion 2-5mg/hr

Tablets: Tricyclic Antidepressants
·         Amitriptyline, Doxepine, Trazadone, Nortriptyline
·         Prolonged QT, Widened QRS
·         3Cs & 1A - Cardiac dysrhythmias, Convulsions, Coma, & Acidosis
·         Rx NaHCO3 bolus or infusions
·         Maintain pH > 7.45

Tablets: Digoxin
·         Toxicity many cause a variety of dysrhythmias
·         Rx Digibind follow normogram in PDR or drug insert for correct dosing information

Tablets: Cocaine
·         Elevates blood pressure
·         Increases cardiac contractility
·         Decreases coronary blood flow
·         Increases coronary vasoconstriction
·         Increases myocardial oxygen consumption

Tablets: Cocaine- Treatment
·         MONA
·         Benzodiazepines- modulates stimulatory effects of cocaine on CNS
·         Avoid  blockers- increases coronary vasoconstriction
·         VT/VF follow ACLS algorithm

Tamponade, cardiac
·         Hx of trauma, chest malignancy
·         Muffled heart sounds
·         Tx: pericardialcentesis

Tension Pneumothorax
·         Hx trauma, recent pacemaker or central line insertion, ventilator patient
·         Assess for tracheal deviation
·         Needle decompression 2nd intercostal space midclavicular line
·         Chest tube

Thrombosis, Coronary
·         MONA
·         Follow ACS algorithm

Thrombosis, Pulmonary
·         Thrombolytics
·         Heparin infusion
·         Surgery


·         Wide QRS: suggests massive myocardial injury, hyperkalemia, hypoxia, hypothermia
·         Wide QRS+Slow: consider drug OD (tricyclics, beta-blockers, Ca-blockers, digoxin)
·         Narrow complex: suggests intact heart; consider hypovolemia, infection, PE, tamponade

Aehlert, Barbara. ACLS Quick Review Study Guide, 2nd edition.  Mosby, inc.  St. Louis, Mo. 1994.
Neumar RW, Otto CW, Link MS, Kronick SL, Shuster M, Callaway CW, Kudenchuk PJ, Ornato JP, McNally B, Silvers SM, Passman RS, White RD, Hess EP, Tang W, Davis D, Sinz E, Morrison LJ. Part 8: adult advanced cardiovascular life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122(suppl 3):S729–S767

Friday, May 25, 2012

Megacode PEA Part 6

·         Look for tachycardia with narrow QRS complex
·         Assess and find bleeding sources
·         Fluid boluses with isotonic crystaloids
·         Volume expanders
·         Blood products

Hydrogen Ions (acidosis)
·         Assess ABGs
·         Bicarb 1mEq/kg
o   Known pre-existing bicarbonate responsive acidosis
o   Intubated patient with continued long arrest interval
o   Upon return of spontaneous circulation after long arrest interval
o   Tricyclic antidepressant or aspirin overdose
o   Known prexisting hyperkalemia
·         ·Treat respiratory acidosis with ventilation

Assess serum potassium levels
Tall T waves, widened QRS
3.5-5.3             Normal
5.3-6.0             Mild
6.1-7.0             Moderate
>7.0                Severe


·         Assess core temperature
·         Cardiac dysrrhythmias when < 86F (30C)
·         Many meds. are ineffective until temp >86F
·         Defibrillation ineffective unless temp >86F
·         Remember  “No patient is dead until he is warm and dead”
·         Hypothermic algorithim

Thursday, May 24, 2012

Megacode PEA Part 5

·         Epinephrine
·         Vasopressin

Note:  Available evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit. For this reason, atropine has been removed from the Cardiac Arrest Algorithm.
To date no placebo-controlled trials have shown that administration of any vasopressor agent at any stage during management of VF, pulseless VT, PEA, or asystole increases the rate of neurologically intact survival to hospital discharge. There is evidence, however, that the use of vasopressor agents is associated with an increased rate of ROSC.

Drug Therapy: Epinephrine
·         Epinephrine 1mg (1:10,000 solution) IV/IO q3-5min
·         ETT dose 2mg diluted in 10cc of NS
·         Increases systemic vascular resistance (vasoconstriction)
·         Increase coronary and cerebral perfusion pressures during CPR
·         Escalating or high doses without demonstrable benefit
·         After drug delivery and approximately 5 cycles (or about 2 minutes) of CPR then recheck the rhythm 

Drug Therapy: Vasopressin
·         Vasopressin 40U IV
·         May be given first or as a second dose to epinephrine
·         Increases systemic vascular resistance
·         After drug delivery and approximately 5 cycles (or about 2 minutes) of CPR then recheck the rhythm

Evaluate Reversible Causes: 5Hs & 5Ts
·         Hypoxia
·         Hypovolemia
·         Hyper/hypokalemia
·         Hydrogen ions (acidosis)
·         Hypothermia

Evaluate Reversible Causes: 5Hs & 5Ts
·         Tension pneumothorax
·         Thrombosis: cardiac
·         Thrombosis: lungs
·         Tables/toxins
·         Tamponade, cardiac

3:26 PM.   With no change in the patient's rhythm after continuous CPR and medications, there was little question that the patient was going to live.   Up to this time, the patient had received some epinephrine, bicarbonate, and fluids but remained in a refractory bradyasystolic rhythm.   There are a lot of factors that weigh in when you reach the decision to stop the code:  the patient's age, co-morbities,  the family's wishes, and quality of life afterwards.  It is not an easy decision.   In my experience, there is usually a general consensus among the team members that every reasonable thing that could have been done for the patient had been done and that any further efforts would not improve the patient's chance of survival.

Consider Termination of Efforts
The final decision to stop can never rest on a single parameter, such as duration of resuscitative efforts. Rather, clinical judgment and respect for human dignity must enter into decision making. In the out-of-hospital setting, cessation of resuscitative efforts in adults should follow system specific criteria under direct medical control.

Wednesday, May 23, 2012

Megacode PEA Part 4

Peripheral IV Drug Delivery
·         Adults peak drug concentrations are lower and circulation times longer
·         Does not require interruption of CPR
·         Administer the drug by bolus injection and follow with a 20-mL bolus of IV fluid
·         Elevate the extremity for 10 to 20 seconds to facilitate drug delivery to the central circulation.

Endotracheal Drug Delivery
·         Results in lower blood concentrations than the same dose given intravascularly.
·         Give 2 to 2½ times the recommended IV dose.
·         Providers should dilute the recommended dose in 5 to 10 ml of water or normal saline and inject the drug directly into the endotracheal tube

Intraosseous Drug Delivery
·         Enables drug delivery similar to that achieved by peripheral venous access at comparable doses.
·         Is safe and effective for fluid resuscitation, drug delivery, and  blood sampling
·         Is attainable in all age groups.

Central IV Drug Delivery
·         Peak drug concentrations are higher and drug circulation times shorter
·         Central line placement can interrupt CPR.
·         a central line extending into the superior vena cava can be used to monitor ScvO2 and estimate CPP during CPR, both of which are predictive of ROSC

IV access on a hemodialysis patient is very challenging.   If peripheral IV access cannot be achieved, then consider intubating the patient and administering the medications through the ET tube.   Remember that peak concentrations are not as good so you will need to administer 2-2.5 times the usual dose of the medication.  

The technology for performing intraosseous access has improved and made it so much easier to obtain IO access on pediatric patients and adults.   So, IO access is another option to consider on those patient with poor peripheral IV access.

On some of the hemodialysis patients that I have resuscitated, I have looked at their functioning dialysis catheter or AV graft and wondered why I could not just administer the medications through them.   If the patient survives, you could always go back and have the graft or dialysis catheter declotted.   Any thoughts on this? 

 3:26 PM.   The rhythm change in response to the epinephrine is an agonal rhythm or a bradyasystolic rhythm.  Given the patient's history, we could consider some possible causes of the PEA rhythm as either hyperkalemia, hypokalemia,  hydrogen ions (acidosis),  hypovolemia,  hypoxia, thrombosis coronary and pulmonary, toxins.

The patient's actual potassium was on slightly elevated at 5.4.   Because metabolic acidosis was a likely problem with this patient, sodium bicarbonate was administered.  The acutal pH could have been determined by an ABG.   In addition, IV fluid boluses were given to the patient because of the potential problem of being hypovolemic related to the dialysis.  In addition, hemodialysis patients typically have a low H&H.   The patient was on a beta blocker so there was the possibility that the drug concentration had built up in the patient's system and slowed the patient's heart rate down.

Tuesday, May 22, 2012

Megacode PEA Part 3

Secondary Survey
·         Intubate and secure airway device.
·         Oxygenate with 100% O2.
·         IV access

Note: Given the potential association of PEA with hypoxemia, placement of an advanced airway is theoretically more important than during VF/pulseless VT and might be necessary to achieve adequate oxygenation or ventilation.

Methods of Confirming ET tube Placement
·         Direct cord visualization
·         End-tidal CO2 monitor
Yellow- yes, tube is correctly placed
Tan- think about it
Purple- problem with tube placement
·         Bilateral breath sounds
·         CXR
·         Continuous waveform capnography

Note:  Continuous waveform capnography is recommended in addition to clinical assessment as the most reliable method of confirming and monitoring correct placement of an endotracheal tube (Class I, LOE A). Providers should observe a persistent capnographic waveform with ventilation to confirm and monitor endotracheal tube placement in the field, in the transport vehicle, on arrival at the hospital, and after any patient transfer to reduce the risk of unrecognized tube misplacement or displacement

Continuous Waveform Capnography
·         Persistently low PETCO2 values (<10 mm Hg) during CPR in intubated patients suggest that ROSC is unlikely
·         If PETCO2 is <10 mm Hg, it is reasonable to consider trying to improve CPR quality by optimizing chest compression parameters

Note:  Although a PETCO2 value of <10 mm Hg in intubated patients indicates that cardiac output is inadequate to achieve ROSC, a specific target PETCO2 value that optimizes the chance of ROSC has not been established. Monitoring PETCO2 trends during CPR has the potential to guide individual optimization of compression depth and rate and to detect fatigue in the provider performing compressions.

3:25 PM.   CPR is in progress with adequate positive pressure ventilations.   The MD ordered another dose of epinephrine to be given.   Although vasoconstrictors will sometimes improve the cardiac output, they do not treat the underlying cause of the problem.   Medications will give you some extra time but it is most important that the underlying cause of the problem be established.   What would be some potential problems  (Hs&Ts)  associated with an older adult with endstage kidney disease who is receiving hemodialysis?

 There was no response to the epinephrine and a rhythm check show the patient to be in asystole.   As you observe the monitor during compression you can often see if the patient develops an organized rhythm.  The complexes will appear between the compressions.   The usual response to a dose of epinephrine is a wide complex tachycardia and the patient will often have a bounding pulse.   Some people want to treat the rhythm as VT and defibrillate it.   But more often than not, it is a response to the epinephrine and the rhythm will begin to slow down as the epinephrine wears off.