Wednesday, June 18, 2014

Practice Rhythm Strips 298

Identify the following rhythms.

1. "I've got rhythm, I've got music....Who could ask for anything more" (Gershwin). Well, I might ask for a couple of medications to treat this rhythm. Name three antiarrhythmics that the AHA recommends for treating this rhythm.







a. Cardizem,  Verapamil,  Amiodarone
b. Amiodarone, Lidocaine, Procainamide
c  Lidocaine,  Adenosine,  Atenolol
d. Procainamide, Amiodarone, Sotalol


2. "Houston, we have a problem."  (Tom Hanks in the movie Apollo 13)










a.  Sinus arrhythmia with sinus arrest
b.  Complete heart block
c.  Ventricular paced with failure to capture
d.  Ventricular tachycardia with brief run of VF


3."Ch-ch-ch-ch-changes.  Turn and face the strange"  (David Bowie from the song Changes)







a. Junctional rhythm changing to NSR
b. Accelerated idioventricular rhythm changing to NSR
c. Accelerated junctional changing to NSR
d. Ventricular tachycardia changing to NSR



4.






a. Atrial fibrillation
b. Atrial flutter
c. Atrial aberrancy
d. Atrial ectopic beats


5.






a. Atrial fibrillation with slow ventricular response
b. Agonal rhythm
c. 3rd degree AV block
d. Idioventricular rhythm


Answers

1.  b. Amiodarone, Lidocaine, Procainamide.  The rhythm is atrial fibrillation changing to ventricular tachycardia.  Amiodorone 150mg IV infused over 10 minutes for wide complex STABLE tachycardia, may repeat if needed, then give maintenance infusion of 1 mg minute for 6 hours, MD may also consider Procainamide 20-50 mg/min gtt infusion until suppressed or hypotension ensues, if continued, maintenance infusion of 1-4 mg/min. Do not use procanimide with CHF or prolonged QT.  Lidocaine 1 - 1.5 mg/kg IV push.  May repeat at 0.5 - 0.75 mg/kg for refractory VT.  Begin maintenance infusion at 1 - 4 mg/min.
2. c.  Ventricular paced with failure to capture.  Ventricular paced rhythm with period of failure to capture. Notice the lower arterial waveform which shows critical drop in arterial blood pressure during the period of failure to capture.
3. c. Accelerated junctional changing to NSR.  This accelerated junctional rhythm abruptly changes to a sinus rhythm.  The wide QRS complex makes it suspicious for an accelerated idioventricular rhythm but the inverted P waves point towards a junctional origin.  The patient has an underlying wide QRS complex, perhaps a LBBB.
4. b. Atrial flutter. There are flutter waves present. The rhythm is irregular with a heart rate of 80/min. Flutter waves are seen in place of the P waves. There is variable conduction of 3:1, 4:1, and 5:1 through the ventricles. This accounts for the irregularity in the rhythm. The QRS complexes are narrow and there are not any ecoptic beats seen. PR: --, QRS: .08, QT: .24 sec. Sometime it is difficult to determine the QT interval especially when a flutter wave is fused on a T wave. Interpretation: Atrial flutter
5. c. 3rd degree AV block.  There are P waves everywhere. The ventricular rate is 40/min and the atrial rate is around 88/min. The P waves are upright, uniform, and divorced from the QRS complexes. The QRS complexes are wide so this points toward a ventricular escape rhythm as our underlying rhythm. No ectopic beats are seen. PR: ---, QRS: .12 sec, QT: .64 sec. Interpretation: 3rd degree AV block.

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