Tuesday, December 30, 2014

Practice EKG Strips 378

Identify the following rhythms.

1.











a. Sinus tachycardia
b. Ventricular tachycardia
c. Atrial fibrillation with RVR
d. Supraventricular tachycardia

2.











a. Atrial paced
b. Ventricular paced
c. Dual paced
d. Biventricular paced

3.











a. Normal sinus rhythm
b. First degree block
c. Sinus bradycardia
d. Second degree heart block type II

4.









a. NSR with sinus arrest and an atrial escape beat
b. NSR with sinus arrest and an junctional escape beat
c. NSR with sinus arrest and an ventricular escape beat
d. NSR with sinus arrest and an supraventricular escape beat



5.









a. Polymorphic VT
b. Coarse VF
c. MAT
d. SVT with aberrancy


Answers
1. c. Atrial fibrillation with RVR. The rhythm is irregular with a rate of 140 bpm. No P waves can be readily identified. Some fibrillation is seen, especially in the V1 lead, between the QRS complexes. If the patient is symptomatic, consider rate slowing medications such as Diltiazem (Cardizem) as a bolus then followed by an infusion.

2. c. Dual paced. The AV interval, the interval between the atrial paced beat and the ventricular paced beat, is prolonged at .24 sec. This gives the ventricle plenty of time to initiate an native beat and delays the onset of a pacemaker induced cardiomyopathy.

3. b. First degree block. Those P waves are way out there. The PR interval is about .44 sec. I say we hold the beta blocker or the calcium channel blocker for another day.

4. a. NSR with sinus arrest and an atrial escape beat. The underlying rhythm is sinus as there is one upright P wave for each QRS complex. A 1.72 second period of sinus arrest follows the 5th complex. An atrial escape beat concludes the first period of arrest. This is followed by a 1.04 second period of sinus arrest. Sinus rhythm resumes and finishes out the rhythm strip.

5. a. Polymorphic VT. If the patient is unstable with this rhythm consider giving an unsynchronized shock. The irregular rhythm makes it hard for the defibrillator to properly synchronize on the R waves so you probably end up giving an unsynchronized shock anyway

Monday, December 29, 2014

Practice EKG Strips 377

Identify the following rhythms.

1.











a. Sinus arrhythmia
b. Sinus rhythm with PACs
c. Sinus rhythm with PVCs
d. Sinus rhythm with pauses

2.













a. Idioventricular rhythm
b. Ventricular tachycardia
c. Junctional rhythm
d. Complete heart block

3.






a. Atrial fibrillation
b. Ventricular fibrillation
c. Torsades de pointes
d. Ventricular tachycardia

4.














a. Demand atrial pacing
b. Demand AV pacing
c. Demand biventricular pacing
d. Demand ventricular pacing

5.






a. 2nd degree heart block type I
b. 2nd degree heart block type II
c. 1st degree heart block
d. Sinus bradycardia with dropped PACs


Answers
1. b. Sinus rhythm with PACs. The rhythm is irregular due to the frequent PACs. The heart rate is around 70 bpm. The PACs are the 3rd, 6th, and 8th complexes. The P waves of complexes 3 and 6 are fused with the T waves of the preceding complexes. A small P wave is seen with the 8th complex.

2.  a. Idioventricular rhythm. The rhythm is irregular. The rate is around 30 bpm. No P waves are seen before the QRS complexes. The QRS complexes are wide, > .12 sec. The rate of an idioventricular rhythm is between 20 and 40 bpm

3. b. Ventricular fibrillation. We are going to shock this rhythm beginning at 200 J biphasic or 360 monophasic.

4. a. Demand atrial pacing. The underlying rhythm is sinus. There is one P wave for each QRS complex. A PJC follows the 4th complex. This is followed by a compensatory pause. This is followed by two atrial paced beats.

5. b. 2nd degree heart block type II with 2:1 conduction. The PR interval on the conducted beats is prolonged, .24 sec. A nonconducted P wave can be seen following each T wave.

Friday, December 26, 2014

Practice EKG Strips 376

Identify the following rhythms.

1.













a. Atrial fibrillation
b. Atrial flutter
c. Atrial tachycardia
d. Atrial paced

2.














a. NSR with a triplet of PVCs
b. Sinus arrhythmia with a triplet of PVCs
c. First degree block with a triplet of PVCs
d. Accelerated junctional rhythm with a triplet of PVCs

3.












a. Sinus arrhythmia
b. Normal sinus rhythm
c. Sinus rhythm with a pause
d. Sinus tachycardia


4.














a. Normal sinus rhythm with sinus arrest
b. Sinus bradycardia with a pause
c. Sinus arrhythmia, sinus bradycardia
d. Complete heart block

5.










a. Atrial flutter changing to VT
b. Sinus rhythm changing to VT
c. Sinus tachycardia changing to VT
d. Accelerated junctional changing to VT

Answers
1. b. Atrial flutter. The rhythm is irregular with a rate of 90 bpm. No P waves are seen just some inverted or retrograde flutter waves. Atrial flutter is thought to be due to a re-entry type mechanism. The conduction to the ventricles varies 1:1 to 3:1. The flutter rate is about 300 bpm. The QRS complexes are narrow. No ectopic beats are seen.

2. d. Accelerated junctional rhythm with a triplet of PVCs. The overall rhythm is regular. The underlying heart rate is around 68 bpm. Retrograde P waves are seen before each QRS complex. Must be something from around the AV junction. The QRS complexes are narrow- indicating normal conduction through the ventricular system. A three beat run of VT or a triplet of PVCs is seen at the end of the strip.

3. a. Sinus arrhythmia. The rhythm is irregular. The R - R interval between the 1st and 2nd complexes is 0.56 sec and the R - R interval between the 5th and 6th complexes is 0.92 sec. The P waves are upright but they tend to flatten out as you progress through the strip. The PR interval appears unchanged though. The QRS complexes are narrow, .08 sec, No ectopy is seen.

4.  b. Sinus bradycardia with a pause. The underlying rate is 53 bpm. The rhythm is irregular due to the pause. Normal conduction resumes after the pause so this is more characteristic of a pause rather than a period of arrest. The P waves are upright and paired with a QRS complex. The QRS complexes are narrow. No ectopic beats are seen

5.  b. Sinus rhythm changing to VT. Some small sinus P waves can be seen on the first two complexes. The PR interval is 0.20 sec, so borderline first degree block. The underlying rate (based on the R - R interval of the two sinus beats) is 88 bpm. The rhythm changes to a polymorphic looking VT.

Thursday, December 25, 2014

Practice EKG Strips Merry Christmas

Identify the following rhythms.

1.











a. NSR with PJCs
b. NSR with PACs
c. NSR with PVCs
d. Sinus rhythm with pauses


2.












a. NSR with sinus arrest
b. 2nd degree heart block type II
c. Sinus arrhythmia
d. NSR with dropped PACs


3.













a. Accelerated idioventricular rhythm
b. Complete heart block
c. Ventricular paced
d. Accelerated junctional rhythm

4.













a. Atrial flutter
b. Atrial fibrillation
c. Atrial tachycardia
d. Atrial paced


5.

















a. Complete heart block
b. Junctional rhythm
c. Sinus arrhythmia
d. Sinus bradycardia with a pause

6.

a. Idioventricular rhythm with a PVC
b. Complete heart block with a PVC
c. Junctional rhythm with a PVC
d. Sinus bradycardia with a PVC

7.










a. Junctional rhythm
b. Atrial fibrillation
c. Sinus bradycardia
d. Complete heart block


8.

a. Supraventricular tachycardia
b. Ventricular tachycardia
c. Multifocal atrial tachycardia
d. Sinus tachycardia

9.














a. Asystole
b. Ventricular fibrillation
c. Ventricular tachycardia
d. Atrial fibrillation

10.






a. Normal sinus rhythm
b. Sinus bradycardia
c. Accelerated junctional rhythm
d. First degree block




Answers

1. b. NSR with PACs. The PACs appear in a bigeminal pattern of every other beat.

2. b. 2nd degree heart block type I. The rhythm is irregular. The P waves are upright. There is progressive increase in the PR interval over successive beats. Some nonconducted P waves are present

3. c. Ventricular paced. The rhythm is regular. The rate is 75 bpm. Up right or positive P waves are seen and have a corresponding QRS complex. An electronic pacer spike appears before each QRS complex. No ectopic beats are noted. PR: .16 sec, QRS: .16 sec, QT: ..52 sec.

4. a. Atrial flutter. I am going to have to go with flutter because the flutter waves are so clear in the V1 lead.

5. d. Sinus bradycardia with a pause. The rhythm is irregular due to the pause. The underlying rate is slow (around 46 bpm) even with the pause. A pause is simply a period of sinus inactivity or absence of a beat. With a pause the rhythm resumes an maintains it's rhythm. Sinus arrest is a period of sinus inactivity but the rhythm does not resume at it's regular pace and rhythm. An inverted T wave is seen and the QT interval is prolonged. No ecopic beats are seen. PR: .16 sec, QRS: .08 sec, QT: .52 sec.

6. b. Complete heart block with a PVC. There is no association between the P waves and the QRS complexes. A P wave can be seen in the ST segment of the first and 4th complexes and on the T wave of the 2nd complex.

7. a. Junctional rhythm.  In this strip the rhythm is regular. The rate is around 40 bpm. There are no P waves seen, In a junctional rhythm this indicates that the atrium and the ventricles are depolarizing at the same time. When a retrograde P wave follows the QRS complex it indicates that the ventricles depolarized before the atria. The QRS complexes are narrow, this indicates normal conduction to the ventricles. There is T wave inversion in lead V1, anterior ischemia. PR: ---, QRS: .08 sec, QT: .56 sec

8. d. Sinus tachycardia The rhythm is regular. The axis of the P waves is positive and they are associated with a QRS complex. The QRS complexes are narrow. A single PVC is seen, the 1st complex. PR: .20 sec, QRS: .08 sec, QT: .28 sec.

9. b. Ventricular fibrillation. The rhythm is irregular with QRS complexes of varying morphology. No P waves are seen. Maybe we should defibrillate at 120 - 200 J (depending upon the defibrillator's manufactures suggested setting). Then a round of vasopressors: epinephrine or vasopressin. You can either continue with the vasopressors or try an antiarrhythmic: amiodarone.

10. a. Normal sinus rhythm.  The rhythm is regular. The rate is 83 bpm. There are upright P waves present and they are associated with a QRS complex. The QRS complexes are narrow. No ectopic beats are seen. PR: .12 sec, QRS: .08 sec, QT: ..36 sec.

Wednesday, December 24, 2014

Practice EKG Strips 374

Identify the following rhythms.

1.













a. Atrial paced
b. AV paced
c. Biventricular paced
d. Ventricular paced

2.












a. Atrial paced with a PAC
b. AV paced with a PAC
c. Biventricular paced with a PAC
d. Ventricular paced with a PAC

3.









a. Demand atrial pacing with frequent PVCs
b. Demand AV pacing with frequent PVCs
c. Demand biventricular pacing with frequent PVCs
d. Demand ventricular pacing with frequent PVCs

4.














a. Atrial paced
b. AV paced
c. Biventricular paced
d. Ventricular paced

5.











a. Atrial paced
b. AV paced
c. Biventricular paced
d. Ventricular paced

Answers

1. a. Atrial paced. The rhythm is regular with a rate of 60 bpm. Very small P waves can be seen in lead V1 after the atrial pacer spike. The QRS complex is wide, .16 sec. It looks like an RSR complex lead V1 which is consistent with a RBBB. There is T wave inversion in the inferior lead II. A very long QT interval is seen of .56 sec too.

2. c. Biventricular paced with a PAC. The PAC is the third beat. The P wave of the PAC is merged somewhat with the T wave of the preceding beat. Two pacer spikes can be seen before each QRS complex.

3. d. Demand ventricular pacing with frequent PVCs. The first beat is native beat. It is followed by a PVC. A compensatory pause follows so two ventricular paced beats kick in. A triplet of PVCs is next then another native beat. Two more demand ventricular paced beats follow.

4. b. AV paced with biventricular pacing.  An atrial pacer spike is seen before the P wave and two pacer spikes are seen before each QRS complex

5.  d. Ventricular paced. The rhythm is regular with a rate of 60 bpm. No P waves are noted. A pacer spike is seen before each QRS complex. No native or ectopic beats are seen.

Tuesday, December 23, 2014

Practice EKG Strips 373

Identify the following rhythms.

1.












a. Atrial fibrillation with slow ventricular response
b. Sinus bradycardia with sinus arrhythmia
c. Complete heart block
d. Junctional rhythm

2.












a. Atrial fibrillation
b. Sinus tachycardia
c. Atrial flutter
d. SVT

3.












a. Atrial paced with a couplet
b. Ventricular paced with a couplet
c. Dual paced with a couplet
d. Biventricular paced with a couplet

4.












a. NSR with a PJC
b. NSR with a PAC
c. NSR with PVC
d. NSR with supraventricular beat

5.











a. 2nd degree heart block type I
b. 2nd degree heart block type II
c. First degree block
d. Complete heart block

Answers
1. a. Atrial fibrillation with slow ventricular response. The rhythm is irregular. The rate is around 40 bpm (The last complex falls outside the 6 second marker). No P waves are seen just some fibrillation. No ectopic beats are seen. The QRS complex is narrow.
2.  c. Atrial flutter with a little rapid ventricular rate. The conduction through the AV node varies so the rhythm is irregular. You can see the flutter waves clearly between the 2nd and 3rd complexes as well as the 8th and 9th complexes.
3. d. Biventricular paced with a couplet. Two pacer spikes before the QRS complex. The 3rd complex also had an atrial paced beat thrown in for good measure. The QRS complex of the ventricular paced beat is usually negative with a T wave that is upright.
4. a. NSR with a PJC is what I am calling it. The PRI on the sinus beats is around .16 sec. On a PAC you would expect the ectopic PRI to be about the same or maybe a little shorter. If you look on the V1 lead you don't really see any indication of a P wave that falls within .16 sec. The other thing I look at is the preceding T wave. Sometimes the P wave of a PAC may be buried within the T wave of the preceding beat. When this occurs, you usually see a change in the amplitude or morphology of that T wave. In this case, The T wave before the ectopic beat looks like the T waves of the other sinus beats. Recall that a the P wave of a PJC may be absent, inverted before the QRS complex, or inverted and follow the QRS complex. In this strip it is absent. That is my story and I am sticking to it.
5. d. Complete heart block.   The P waves and the QRS complexes are dissociated. The atrial rate is around 125 bpm and the ventricular rate is around 62 bpm.   The QRS complexes are 0.10 sec.  The overall rate points towards a underlying junctional escape rhythm and a high degree AV block.

Monday, December 22, 2014

Practice EKG Strips 372

Identify the following rhythms.

1.











a. Normal sinus rhythm with a run of SVT
b. Normal sinus rhythm with a run of VT
c. Normal sinus rhythm with a run of AIVR
d. Normal sinus rhythm with a run of ST

2.














a. Junctional rhythm
b. Complete heart block
c. Sinus bradycardia
d. Idioventricular rhythm

3.













a. Sinus bradycardia with ST depression and a PVC
b. Sinus rhythm with ST depression and a PVC
c. Junctional rhythm with ST depression and a PVC
d. First degree block with ST depression and a PVC

4.












a. Ventricular tachycardia
b. Atrial fibrillation
c. Ventricular fibrillation
d. Ventricular standstill

5.











a. NSR with a PVC followed by more PVCs
b. NSR with a PVC followed by junctional escape beats
c. NSR with a PVC followed by atrial escape beats
d. NSR with a PVC followed by some PACs

Answers
1.  a. Normal sinus rhythm with a run of SVT. The run is fairly regular and there is an absence of P waves. The QRS complex is narrow so this is something from above the ventricles.
2. c. Sinus bradycardia. I should have put NSR instead of SB. Technically SB is less than 60 and here the rhythm is exactly 60 bpm. The rhythm is regular. There is an upright P wave before each QRS complex. No ectopic beats are seen.
3. a. Sinus bradycardia with ST depression and a PVC. There is a compensatory pause that follows the PVC. The rhythm is otherwise regular. There is one P wave for each QRS and they are upright so we are looking at something sinus in origin. The QRS complexes are narrow. That is good. There is some ST depression which is indicative of ischemia. That is not good. Lead II is an inferior lead so we have some ischemia in the RCA.
4. c. Ventricular fibrillation
5. b. NSR with a PVC followed by junctional escape beats. The rhythm starts out as sinus rhythm. A PVC is seen (the 8th complex) this is followed by a pause lasting 0.8 sec. The AV junction fires off with a escape beat. There is no P wave associated with the ectopic beat and the QRS is narrow so it is from the junctional area. This is followed by another pause of .92 seconds and the AV junction fires again with another junctional escape beat. Sinus rhythm resumes afterwards.

Friday, December 19, 2014

Practice EKG Strips 371

Identify the following rhythms.

1.











a. Sinus tachycardia
b. Supraventricular tachycardia
c. Atrial fibrillation with RVR
d. Ventricular tachycardia

2.













a. Complete heart block
b. Junctional rhythm
c. Sinus bradycardia
d. Sinus arrhythmia

3.











a. Sinus tachycardia
b. Sinus rhythm
c. Accelerated junctional rhythm
d. Accelerated idioventricular rhythm

4.











a. Atrial paced with a couplet
b. AV paced with a couplet
c. Biventricular paced with a couplet
d. Ventricular paced with a couplet

5.






a. NSR with multifocal PVCs
b. NSR with bigeminal PVCs
c. NSR with trigeminal PVCs
d. NSR with quadrigeminal PVCs


Answers
1. c. Atrial fibrillation with RVR. Overall I think it is afib with RVR. At times it looks like there might be some P waves present but they are not consistent. If it were MAT then we would see more consistent P wave of varying morphology. If it were SVT then we would see a very regular rhythm. If it were ST then there would be one P wave for every QRS complex and the rhythm would be regular. If it were VT then then the QRS complexes would be > .12 sec.
2. a. Complete heart block. The QRS complex is narrow so the block is at the level of the AV node
3. b. Sinus rhythm. Biphasic P waves (P mitrale) due to left atrial enlargement. The terminal portion of the P wave is prolonged due to increased muscle mass of the left atrium
4. d. Ventricular paced with a couplet. The underlying rhythm looks like atrial fibrillation. Pacemaker spikes are seen before the QRS complexes. A multifocal couplet is seen towards the end of the strip.
5. d. NSR with quadrigeminal PVCs.  Unfocal PVCs are seen every 4th beat.

Thursday, December 18, 2014

Practice EKG Strips 370

Identify the following rhythms.

1.











a. Atrial paced
b. Biventricular paced
c. Dual paced
d. Ventricular paced

2.










a. Normal sinus rhythm changing to VT
b. Sinus bradycardia changing to VT
c. Atrial fibrillation changing to VT
d. Idioventricular rhythm changing to VT

3.














a. Accelerated idioventricular rhythm
b. Accelerated junctional rhythm
c. Idioventricular rhythm
d. Junctional rhythm

4.











a. NSR with a sinus exit block
b. NSR with a PAC
c. Sinus arrhythmia
d. Sinus rhythm with a dropped PAC

5.






a. Sinus arrhythmia
b. Sinus rhythm with sinus arrest
c. Sinus rhythm with bigeminal PACs
d. 2nd degree heart block type II

Answers
1. d. Ventricular paced. A single pacer spike is seen just before the QRS complex.
2. c. Atrial fibrillation changing to VT. The initial rhythm is irregular with an absence of P waves. This changes into a ventricular tachycardia with a rate between 150 - 180 bpm.
3. b. Accelerated junctional rhythm . Negative or inverted P are indicative of a junctional rhythm. When the rate is between 60 - 100 bpm then the junctional rhythm is characterized as an accelerated junctional rhythm.
4. a. NSR with a sinus exit block
5. c. Sinus rhythm with bigeminal PACs . You can see somethig of a pattern to the rhythm. The first two complexes are sinus in nature and may be indicative of the underlying rate and rhythm. The 3rd, 5th, 7th and 9th complexes arrive early in the cardiac cycel by comparison. There is also a slight morphological difference in the ectopic P waves.