Friday, January 30, 2015

Practice EKG Strips 399

Identify the following rhythms.

1.










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

2.











a. Atrial flutter
b. 2nd degree heart block type II
c. Atrial fibrillation
d. 2nd degree heart block type I

3.










a. NSR with unifocal PACs
b. NSR with multifocal PVCs
c. NSR with bigeminal PVCs
d. NSR with multiform PVCs

4.











a. Sinus bradycardia with PACs
b. Sinus arrhythmia with PVCs
c. Complete heart block
d. Atrial fibrillation with slow ventricular

5.










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


Answers
1. Atrial fibrillation with RVR. The rhythm is very irregular so this cannot be SVT which has a regular rhythm. The QRS complexes appear to be a little wide but there appears to be some fibrillation between some of the QRS complexes. This is not something that you would see with VT. With MAT you would need to see some consistent P waves across the strip. On complexes 4, 5, and seven you can't be sure if that small positive deflection is part of the T wave. There appears to be some fibrillaton between the 7 - 8 and 11 - 12 complexes.

2. a. Atrial flutter.   The rhythm is regular with a rate of 50 bpm.   3:1 flutter waves are seen between the QRS complexes.  The QRS complexes are wide, .12 sec.  No ectopic beats are seen.

3. c. NSR with bigeminal PVCs. The rhythm is irregular due to the PVCs.  There upright P waves associated with the sinus QRS complexes. Unifocal PVCs every other beat.  PR: .20 sec, QRS: .08 sec, QT: .40 sec.

4.  c. Complete heart block. There is no relationship between the P waves and the QRS complexes. The P waves can be seen landing on the T waves and on the QRS complexes.

5. Sinus bradycardia with a U wave. The P - P interval is shorter from the P wave to what I will call the U wave when compared to the P - P interval from the U wave to the P wave. With a type II block the P - P interval is usually very regular. It would be very unusually to see so many consecutive dropped PACs, it is possible but nothing you would typically see.

Thursday, January 29, 2015

Practice EKG Strips 398

Identify the following rhythms.

1.










a. Atrial fibrillation
b. 2nd degree heart block type I
c. First degree block
d. Sinus arrhythmia

2.






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


3.









a. AV paced changing to VT
b. AV paced changing to SVT
c. AV paced changing to AIVR
d. AV paced changing to MAT

4.






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

5.










a. Sinus bradycardia changing to AIVR
b. Sinus bradycardia changing to VT
c. Sinus bradycardia with multiple PVCs
d. Sinus bradycardia with SVT

Answers
1. b. 2nd degree heart block type I. The PR interval just gets long (.24 sec), longer (.28 sec), and longer (.32 sec) until there is a nonconducted P wave, seen after the 2nd 4th, and 7th complexes

2. a. Atrial flutter. It looks like 3:1 flutter waves for every QRS complex.

3. C. AV paced changing to AIVR. There is a wide variety of ranges in the rate given to AIVR, 50 – 110 bpm, 40 – 120 bpm , 60 -100 bpm , 60 - 110 bpm. Not everybody is in agreement. The rates for VT are generally are 150 - 120 although some texts describe a slow VT with a rate less than 150. I chose AIVR just because the rate between the complexes is somewhat slow, 108 - 115 bpm. If you chose answer A then that is okay too. The QRS complexes would have to be much more narrow for it to be answer B and there would have to be visible P waves for it to be answer D.

4. c. Sinus bradycardia. Did somebody mention atropine? This is an extreme sinus bradycardia with a rate of 21 bpm. It is sinus because there are upright P waves before each QRS complex. The PR interval is a little prolonged, 0.24 sec. The QRS is wide, .12 sec, and there is an rSR complex in the V1 lead, RBBB. The QT interval is prolonged too, .68 sec

5. a. Sinus bradycardia changing to AIVR. The initial rhythm is slightly irregular with a rate of 55 bpm. The P waves and the QRS complexes are paired up. The P waves are somewhat flattened but are upright. The QRS complexes are wide, 0.12 sec. The 4th beat arrives early and may be an initial PVC but it is followed by some ventricular escape beats. The rate of the escape rhythm is around 50 bpm which is what we would expect for an accelerated idioventricular rhythm. No P waves are seen and the QRS complexes are wide and different looking from the sinus QRS complexes. Answer B is incorrect because the rate is much too slow for VT. Answer C is not correct because the beats arrive LATE in the cardiac cycle, not early or prematurely. Answer D is incorrect because the rate is too slow and the QRS complexes are wide, not narrow

Wednesday, January 28, 2015

Practice EKG Strips 397

Identify the following rhythms.

1.










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

2.











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

3.











a. Atrial paced
b. AV with biventricular pacing
c. Demand ventricular pacing
d. Ventricular paced

4.











a. Atrial paced with multifocal PVCs
b. Biventricular paced with demand atrial pacing and trigeminal PVCs
c. Atrial paced with demand biventricular pacing and PVCs
d. Demand AV pacing with PVCs

5.







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


Answers
1. a. Demand atrial pacing.  The rate is about 70 bpm. The QRS complexes are wide with an rSR complex in the V1 lead, RBBB.  No ectopic beats ares seen. The A-V interval is .24 sec.  QRS: .12 sec, QT: .44 sec
2. b. Demand ventricular pacing.  The rhythm is irregular with a rate of 70.  In lead V1 there are some unassociated P waves seen.  Maybe there is an underlying complete heart block.  
3. b. AV with biventricular pacing.  The A-V interval is .20 sec.  The V-A interval is around .64 sec.
4. b. Biventricular paced with demand atrial pacing and trigeminal PVCs
5. c. Biventricular pacing.   It looks like the underlying rhythm is atrial fibrillation

Tuesday, January 27, 2015

Practice EKG Strips 396

Identify the following rhythms.

1.






a. 2nd degree heart block type II
b. Idioventricular rhythm
c. Sinus bradycardia
d. Complete heart block

2.






a. Sinus bradycardia
b. Sinus arrest
c. Atrial fibrillation with slow ventricular response
d. 3rd degree heart block

3.













a. Agonal rhythm
b. Idioventricular rhythm
c. Junctional rhythm
d. Complete heart block

4.










5.













a. Sinus arrhythmia
b. Sinus arrest
c. 3rd degree heart block
d. Junctional rhythm


Answers
1. d. Complete heart block. The ventricular rate is 30 bpm and the atrial rate is 71 bpm. There is no conduction between the atria and the ventricles- each are beating independently of one another. So there is a significant drop in the cardiac output associated with this rhythm. As long as the patient remains at rest sometimes this rhythm is tolerated. However, when increased demand is on the body then the heart is unable to compensate by increasing the cardiac output and the patient becomes hemodynamically unstable.

2. c. Atrial fibrillation with slow ventricular response. The rhythm is irregular. The rate is around 30 bpm. No P waves are seen. So this rules out answers A, B, and D. Sometimes with slow atrial fibrillation the fibrillation is not as coarse and the rhythm tends to look almost regular. Often with a slow atrial fibrillation you are looking at a rhythm that has been caused by too much beta blocker, digoxin, or calcium channel blockers. Witholding these meds will usually restore the rate.

3. a. Agonal rhythm. The rate is around 15 bpm. No P waves are seen. The QRS complexes are wide. There is ST elevation.

4. c. Junctional rhythm. The rhythm is regular. The rate is around 48 bpm. There are P waves but they are inverted. This points toward a pacemaker site below the level of the atrium. The QRS complexes are narrow. No ectopic beats are seen. PR: .12 sec, QRS: .08 sec, QT: .28 sec. Since the rate is between 40 and 60 beats per minute we are looking at a junctional rhythm. Rates between 60 and 100 bpm would be accelerated junctional rhythm. Rates over 100 would be junctional tachycardia

5. b. Sinus arrest. The rhythm is irregular due to long period of sinus arrest. The underlying rhythm has upright P waves so it is sinus in origin. The P waves ae associated with a QRS complex. There is some rather significant ST elevation in this lead. If found in other the continguous leads of III, and aVF it would be significant for an inferior MI. PR: .16 sec, QRS: .08 sec, QT: .40 sec.

Monday, January 26, 2015

Practice EKG Strips 395

Identify the following rhythms.

1.











a. Wandering atrial pacemaker with a PVC
b. Ventricular tachycardia with a PVC
c. Sinus tachycardia
d. Junctional tachycardia

2.











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

3.













a. Accelerated idioventricular rhythm
b. Ventricular tachycardia
c. Ventricular fibrillation
d. Sinus tachycardia with aberrancy

4.










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

5.











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


Answers
1. c. Sinus tachycardia. Very distinct and uniform P waves are seen. The presence of upright P waves rules out answers B and D. The uniformity of the P waves rules out answer A. In MAT there are at least three P waves of varying morphology or shape. The rhythm is regular with a rate of 136 bpm. The P waves are paired with a QRS complex. The QRS complexes are narrow. There is also some ST-T depression. No ectopic beats are seen.
2. d. Supraventricular tachycardia. The rhythm is regular with a rate of of 166 bpm. No P waves are readily identified. The P wave looking complexes are actually T waves. The QRS complex is wide. No ectopic beats are seen. PR: ---, QRS: 10 sec, QT: .36 sec.
3. b. Ventricular tachycardia. The rhythm is regular with a rate of 166 bpm. No P waves are seen. The QRS complexes are wide, .16 sec.
4. b. Ventricular fibrillation
5. a. Atrial fibrillation with RVR. The rhythm is very irregular. The rate is about 130 bpm. No P waves are seen. The QRS complexes are narrow. No ectopic beats are identified.

Friday, January 23, 2015

Practice EKG Strips 394

Identify the following rhythms.

1.






a. Atrial flutter with rapid ventricular response
b. Ventricular fibrillation
c. Atrial fibrillation with rapid ventricular response
d. Multifocal atrial tachycardia

2.










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

3.












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

4.










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


5.












a. Sinus rhythm with 1st degree block
b. Sinus bradycardia with 1st degree block
c. Sinus arrhythmia with 1st degree block
d. Sinus arrest with 1st degree block

Answers
1. a. Atrial flutter with rapid ventricular response
2. b. Biventricular paced with a PVC
3. b. Junctional rhythm with a PVC
4. d. NSR with multifocal PVCs
5. b. Sinus bradycardia with 1st degree block

Thursday, January 22, 2015

Practice EKG Strips 393

Identify the following rhythms.

1.







a. Atria flutter
b. Atrial paced
c. Atrial fibrillation
d. Wandering atrial pacemaker

2.











a. 2nd degree heart block type I
b. 3rd degree block
c. Idioventricular rhythm
d. Junctional rhythm


3.











a. Sinus arrhythmia
b. Sinus arrest
c. 1st degree block with a pause
d. Atrial fibrillation

4.






a. Atrial fibrillation
b. Sinus arrhythmia
c. NSR with PACs
d. Mobitz I

5.  What is the post shock rhythm?






a. Ventricular fibrillation
b. Ventricular tachycardia
c. Polymorphic ventricular tachycardia
d. Torsades de pointes

Answers
1. a. Atria flutter. An irregular atrial flutter. Sometimes you will hear it referred to as atrial flutter with variable ventricular response. The strip has a bigeminal pattern to it. Every other beat there is one flutter wave for every QRS complex.
2. b. 3rd degree block. The P waves and the QRS complexes are NOT paired up. The atrial rate is around 68 bpm. The ventricular rate is about 53 bpm.
3. c. 1st degree block with a pause. The rhythm is irregular due to the pause. The P waves have a corresponding QRS complex. The PR interval is prolonged. The QRS complexes are narrow and there is some ST-T wave depression. There is a 1.28 second pause present. PR: .22 sec, QRS: .08 sec, QT: 40 sec.
4. c. NSR with PACs. The rhythm is irregular with a rate of 70 bpm. There are upright P waves before each QRS complex. The QRS complexes are narrow. PACs are seen (beats 3, 6, and 9) every third beat, atrial trigeminy. The P wave of the PAC has a different shape from the sinus P waves. PR: .12 sec, QRS: .08 sec, QT: .44 sec.
5. a. Ventricular fibrillation

Wednesday, January 21, 2015

Practice EKG Strips 392

Identify the following rhythms.

1.









a. Ventricular tachycardia changing to SVT
b. Ventricular tachycardia changing to AIVR
c. Ventricular tachycardia changing to wide complex tachycardia
d. Ventricular tachycardia changing to sinus tachycardia

2.











a. Sinus bradycardia with trigeminal PVCs
b. Sinus rhythm with a 3 beat run of SVT
c. Sinus bradycardia with a run of VT
d. Sinus rhythm with a triplet of PVCs

3.











a. Atrial fibrillation
b. Junctional rhythm
c. Sinus bradycardia
d. Accelerated idioventricular rhythm

4.











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

5.











a. Sinus bradycardia with PACs
b. Sinus bradycardia with sinus arrhythmia
c. Sinus bradycardia with a first degree block
d. Sinus bradycardia with pauses


Answers
1. c. Ventricular tachycardia changing to wide complex tachycardia. Clearly there is VT at the beginning of the strip. This changes to a fast rhythm with a wide QRS complex. We can't be sure if we are seening P waves or T waves because the rate is so fast. Because of the wide QRS complexs, the rhythm does not "fit" the characteristics of SVT which normally has narrow QRS complexes. The RSr appearance of the QRS complexes in the V1 lead do provide us with a clue that the underlying rhythm has a RBBB. This would explain the wide QRS complexes that we see at the end of the VT. In the top lead there is also some ST depression. So we are looking at some SVT with aberrancy or wide complex tachycardia. Adenosine would be a drug to consider for the SVT if the patient is only symptomatic. If the patient is unstable then cardioversion- which might take care of both rhythms in the long run.
2. d. Sinus rhythm with a triplet of PVCs. The rhythm is irregular due to the PVCs. The rate is around 68 bpm. The P waves are positive, upright and are hooked up with a QRS complex. The QRS complexes are wide, .12 sec. The morphology of the PVCs does vary some. Maybe multifocal in origin. PR: .20 sec, QRS. 12 sec, QT: .40 sec
3. b. Junctional rhythm. The rhythm looks regular. The rate is around 48 bpm. Inverted P waves are seen before each QRS complex. The QRS complexes are narrow. No ectopic beats are seen. PR: .10 sec, QRS: .08 sec, QT: .32 sec.
4. a. Atrial paced.  The rhythm is regular with a rate of  75 bpm.   There are pacer spikes seen before each P wave.  The QRS complexes are narrow.  No ectopic beats are seen.  PR: .20.  QRS: .08 sec, QT: .44 sec.
5. b. Sinus bradycardia with sinus arrhythmia.   The rhythm is irregular with a rate of 50 bpm.  There are upright P waves before each QRS complex.  The QRS complexes are narrow.  The T waves are peak.  This may represent hyperkalemia or hyperacute changes.  No ectopic beats are noted.  PR: .20 QRS: .08 sec, QT: .42 sec

Tuesday, January 20, 2015

Practice EKG Strips 391

Identify the following rhythms.

1.










a. Sinus rhythm with unifocal PVCs
b. Sinus rhythm with multifocal PVCs
c. Sinus rhythm with bigeminal PVCs
d. Sinus rhythm with polymorphic VT

2.









a. Sinus rhythm changing to SVT
b. Sinus rhythm changing to VT
c. Sinus rhythm changing to AIVR
d. Sinus rhythm changing to MAT

3.














a. AV pacing with demand ventricular pacing
b. AV pacing with atrial failure to capture
c. AV pacing with demand biventricular pacing
d. AV pacing with demand atrial pacing

4.











a. Sinus bradycardia with unifocal PVCs
b. Sinus rhythm with PACs
c. Sinus arrhythmia
d. Wenckebach

5.











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


Answers
1. b. Sinus rhythm with multifocal PVCs. Lots of PVCs of varying morphology.
2. a. Sinus rhythm changing to SVT. The rate of the SVT is around 150 bpm. No P waves are observed. The QRS complexes are narrow so this rules out answer B and C. No P waves of varying morpholoy are seen so this rules out answer D.
3. d. AV pacing with demand atrial pacing. Ventricular paced with some demand atrial pacing. All the QRS complexes have a ventricular pacer spike. Some are AV or dual paced. There is a native P wave on the 1st, 4th, and 6th complexes.
4. b. Sinus rhythm with PACs. P waves are seen every other beat. The morphology of the ectopic P waves are different from the those of the sinus beats.
5. The P waves and the QRS complexes should have not relationship in CHB. Here there is a relationship but the P waves and the QRS complexes are no longer close and appear to be drifting away from one another. Sounds like a soap opera.

Monday, January 19, 2015

Practice EKG Strips 390

Identify the following rhythms.

1.












a. First degree heart block
b. Second degree heart block type I
c. Second degree heart block type II
d. Third degree heart block

2.














a. 1st degree heart block
b. 2nd degree heart block type I
c. 2nd degree heart block type II
d. 3rd degree heart block

3.











a. 1st degree heart block
b. Wenckebach
c. Mobitz II
d. Complete heart block

4.












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

5.









a. 1st degree heart block with a run of VT
b. 2nd degree heart block type I with a run of VT
c. 2nd degree heart block type II with a run of VT
d. 3rd degree heart block with a run of VT



Answers
1. A. First degree block. The rhythm is regular with a rate around 83 bpm. The P waves are upright and paired with a QRS complex. The PR interval is prolonged at .22 sec. The QRS complexes are wide, .12 sec. The QT interval is about .40 seconds. No ectopic beats are seen.

2.  d. 3rd degree heart block.  There is no association or pattern between the P waves and the QRS complexes. In fact on the 2nd, 3rd, and 5th complexes a P wave falls on the T waves. This only happens when there is complete AV dissociation. Now, if this were a type one block then there would be progressive elongation of the PRI over successive beats. When looking at the strip you can see that the PR interval of the 2nd complex is much longer than the PR interval of the 3rd complex. If this were a type II block then all the QRS complexes would be paired with a P wave and the PRI would measure out the same. There would also be some additional non-conducted P waves.

3.  B. Wenckebach pattern.   On the first two complexes there is progressive prolongation of the PR interval over successive beats. This is followed by a dropped beat.   This is followed by a pause and a single beat.  This is not a typical pattern for Wenckebach.  A dropped beat follows the 4th complex.  Then the 2 beat series resumes.

4. C. 2nd degree AV block type II. Two non-conducted P waves are seen at the beginning of the strip. The next three beats are sinus in origin. The PR interval on the couched beats is the same from beat to beat. Two more non-conducted beats finish out the strip. If you were to measure the P - P interval then you would find it to be consistent across the strip

5. A. 1st degree heart block with a run of VT. The underlying rate is around 65 bpm. The P waves are positive and associated with a QRS complex. The PR interval is prolonged at .24 seconds. The QRS complexes are narrow at .08 seconds. The QT interval is around .40 seconds. There is a four beat run of VT.