Friday, February 27, 2015

Practice EKG Strips 219

Identify the following rhythms.

1.













a. Sinus arrhythmia
b. Sinus rhythm with PACs
c. Second degree heart block type I
d. NSR with PVCs

2.














a. Junctional tachycardia
b. Atrial tachycardia
c. Sinus tachycardia
d. Supraventricular tachycardia

3.













a. Sinus tachycardia with PVCs
b. Supraventricular tachycardia with PVCs
c. Wandering atrial pacemaker with PVCs
d. Multifocal atrial tachycardia with PVCs

4. A 45 year old female comes to the ER with complaints of shortness of breath with exertion, palpitations, and dizziness. VS: 98.4-188-20. BP: 105/73. Sats: 93% on room air. She is taken to an ER room and a # 20 IV is started in her left AC and blood work drawn. She is placed on the monitor and the following rhythm is seen. Vagal maneuvers are attempted but without a change in the rhythm. The MD orders Adenosine to be given. Which of the following statements is true regarding Adenosine:












a. It is an antiarrhythmic used to treat SVT
b. The initial dose is 6 mg given over 1 minute
c. It may cause a brief period of sinus arrest
d. It can be repeated at 1.5 x the initial dose

5.














a. Atrial fibrillation
b. Sinus arrest
c. Sinus arrhythmia
d. Wandering atrial pacemaker



Answers
1. c. Second degree heart block type I. The rhythm is irregular. The rate is 70/min. You can see that the PR interval tends to get longer from beat to beat. A dropped P wave follows the 1st, 3rd, 5th, and 7th complexes. The P - P interval is constant

2. a. Junctional tachycardia. The rhythm is regular. The rate is around 115 bpm. No P waves are seen. The QRS complexes are narrow. No ectopic beats are seen- how boring. PR:---, QRS: .08 sec, QT: 28 sec.

3. a. Sinus tachycardia with PVCs. The rhythm is irregular due to the PVCs. The rate is around 115/min. The P waves are pointing upward and are associated with a QRS complex. There is a deep Q wave seen in lead II, possibly an old MI. There are some unifocal PVCs. PR: ..16 sec, QRS: .12 sec, QT: .32 sec.

4. c. It may cause a brief period of sinus arrest. I did not pull the wool over your eyes on this one. Answer B is incorrect because you give Adenosine very fast, over 2-3 seconds. Even though Adenosine is used to treat a arrhythmia, it is technically called a nucleoside. D is incorrect because you double the dose on the second dose.

5. a. Atrial fibrillation. The rhythm looks irregular. The rate is around 60 per minute. No P waves are seen just some fibrillation between the QRS complexes. The QRS complexes are wide. No ectopic beats are seen. PR: --, QRS: .12 sec, QT: .48 sec.

Thursday, February 26, 2015

Practice EKG Strips 418

Identify the following rhythms.

1. A 34 year old female is brought by her husband to the ER with complaints of weakness, palpitations, chest pain, shortness of breath, and nausea VS 98.4-188-30. BP 90/56. Sat 92%. She is placed on the monitor and the following rhythm is noted. An IV is started and oxygen administered at 2L/min. A trial dose of adenosine 6 mg is given while setting up for cardioversion. There was is no change in the rhythm. What is the recommended initial joule setting for cardioversion of SVT?











a. 50 J
b. 150 J
c. 200 J
d. 250 J

2. During a code in the ER of a 56 year old with a history of cocaine use, you pause for a rhythm check and note the following rhythm. What is the rhythm?












a. Ventricular tachycardia changing to torsades de pointes
b. Ventricular tachycardia changing to ventricular fibrillation
c. Ventricular tachycardia changing to atrial fibrillation
d. Ventricular tachycardia changing to polymorphic VT

3. During a cardiac arrest in the ER a patient receives a second shock at 200 J. Assessment of the post shock rhythm shows the following wide complex organized rhythm. However the patient remains pulseless and apneic. CPR is resumed. What is the next appropriate intervention or medication for this patient?











a. Continue CPR at a rate of 100 compression/min
b. Given Amiodarone 300 mg IV
c. Give Atropine 0.5 mg IV
d. Begin transcutaneous pacing at a rate of 80 bpm

4. During a cardiac arrest in the ER a patient receives a second shock at 200 J. A post shock analysis of the rhythm is done and the following rhythm changes are noted. What is the next appropriate intervention?











a. Give Vasopressin 40 units IV
b. Continue CPR with positive pressure ventilations
c. Check for a pulse
d. Prepare to defibrillate at 360 J after the next cycle of CPR is completed

5. What two medications are recommended to treat this pulseless rhythm?










a. Atropine and epinephrine
b. Epinephrine and vasopressin
c. Amiodarone and epinephrine
d. Epinephrine and lidocaine

Answers
1. a. 50 J.   The actual dose range is 50 - 100 J

2. b. Ventricular tachycardia changing to ventricular fibrillation

3. a. Continue CPR at a rate of 100 compression/min. The patient is pulseless so pacing will not really work. Atropine is given for symptomatic bradycardia. The rhythm is too slow for amiodarone.

4. c. Check for a pulse. An organized rhythm. It won't hurt to check for a pulse.

5. b. Epinephrine and vasopressin.  

Wednesday, February 25, 2015

Practice EKG Strips 417

Identify the following rhythms.

1.














a. Idioventricular rhythm
b. Complete heart block
c. Sinus bradycardia with a wide QRS complex
d. Atrial flutter with slow ventricular response

2.












a. Sinus arrhythmia
b. Sinus rhythm with PACs
c. Atrial fibrillation
d. Wandering atrial pacemaker

3. A 70 year old with a history of persistent atrial fibrillation undergoes elective cardioversion. She receives Versed 3 mg prior to the cardioversion. Oxygen is at 2 L/min via nasal cannula. An initial attempt at 150 J shows the following rhythm changes. What is the next appropriate intervention for this patient?











a. Place the defibrillator in the synch mode and cardiovert at 200 J
b. Increase the joule setting to 200 J and shock again
c. Check for a pulse and monitor the rhythm
d. Give adenosine 6 mg IV and re-cardiovert at the same or a higher joule setting.

4. A 79 year old who lives alone is brought to the ER by her family because increasing dizziness, chest discomfort, shortness of breath and near syncopal episodes at home. History: Hypertension. Atrial fibrillation. CHF Home meds: Digoxin 0.125 mg daily. Lisinopril 10 mg daily. VS: 97.2-36-28. BP 85/42. Sats 93%. She is somewhat pale and diaphoretic. She is taken to a room and placed on a monitor and the following rhythm is seen. An IV and oxygen are started. Lab work is sent off, including a digoxin level. What intervention is appropriate to treat this rhythm?











a. Atropine 1 mg IV
b. Dopamine 5 - 10 mcg/kg/min
c. Digibind 1 vial
d. Epinephrine 1 mg IV

5. A 68 year old male is brought to the ER by EMS with unstable bradycardia due to complete heart block. Transcutaneous pacing is in progress. After transferring the patient to the ER stretcher the following rhythm is noted on the monitor. VS: 98.0-83-24. 94/46. What adjustments should be made to the transcutaneous pacemaker at this time?











a. Increase the milliamps
b. Assess for mechanical capture by checking for a pulse and BP
c. Decrease the milliamps to the pacing threshold
d. Increase the rate to 100 bpm


Answers
1. b. Complete heart block. The P waves are seen better in lead V1. They are not associated with the QRS complexes. The atrial rate is about 150. The ventricular rate is around 44 bpm.

2. b. Sinus rhythm with PACs. The rhythm is irregular. The rate is 90 bpm. Upright P waves are seen before each QRS complex. The QRS complex looks wider than normal. Two PACs are seen, the 3rd complex and the last complex. The P wave of the PAC is buried within the T wave of the preceding complex. PR: .20 sec, QRS: .12 sec, QT: .40 sec

3. c. Check for a pulse and monitor the rhythm. It is kind of slow but we have some sinus beats. Continue to monitor according to post conscious sedation protocol.

4. b. Dopamine 5 - 10 mcg/kg/min.  A is incorrect dose and she has a block, C is incorrect dose, she has a pulse so I'm going with dopamine to increase rate and pressure, while waiting for labs. Digibid can be lethal if used when K+ is low and can throw pt into very unstable rhythm.

5. b. Assess for mechanical capture by checking for a pulse and BP.  The pulse rate should match the pacing rate. Increase the mA a little beyond the pacing threshold if that has not already been done. The pacing treshhold is the point where you either gain or lose electrical capture. As a safety precaution increase the milliamps by 10 to 20% beyond that to ensure that you do not lose capture. Loss of capture may happen if the patient moves around alot which will create poor pad to skin contact. 

Tuesday, February 24, 2015

Practice EKG Strips 416

Identify the following rhythms.

1.






a. Idioventricular rhythm
b. Demand ventricular rhythm
c. Junctional rhythm
d. Atrial paced

2. After experiencing several episodes of this rhythm, the MD orders an Amiodarone drip beginning with a bolus dose. What is the usual loading dose for an Amiodarone infusion?











a. 150 mg IV over 10 minutes
b. 200 mg IV over 10 minutes
c. 250 mg IV over 10 minutes
d. 300 mg IV over 10 minutes

3. A 75 year old arrives to the ER in cardiac arrest. CPR is in progress. He has received two shocks at 200 J and 300 J as well as two doses of epinephrine 1 mg in route. As he is transferred to the stretcher and placed on the monitor, the following rhythm is observed. What medication is indicated in the treatment of this dysrhythmia?














a. Vasopressin 40 units IV
b. Procainamide 20 mg/min
c. Magnesium 1 -2 gm IV
d. Amiodarone 150 mg IV


4.













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

5.











a. Atrial fibrillation
b. Sinus arrhythmia
c. Sinus rhythm with PACs
d. Sinus arrest



Answers
1. b. Demand ventricular rhythm.  The rhythm is irregular.  The rate is 70/min.  No P waves are seen. The first complex is ventricular paced.  This is followed by three native beats.  No P waves are seen with these beats.  The rhythm is regular and the QRS complexes are wide.  This is characteristic of an accelerated idioventricular rhythm- perhaps an escape rhythm in this escape.  Ventricular pacing resumes with the fifth complex. The morphology of the 5th beat is different from the other paced beats.  Probably a fusion beat.
2. A. 150 mg IV over 10 minutes. Then 1 mg/min for 6 hours then 0.5 mg/hr for 18 hr

3. c. Magnesium 1 -2 gm IV

4. b. Accelerated junctional rhythm. The rhythm is regular with a rate of 78/min. No P waves are seen. The QRS is narrow. The is ST about 3 mm ST elevation. No ectopic beats are seen. PR: --, QRS: .08 sec, QT: .40 sec.

5. b. Sinus arrhythmia. Notice the big difference between the R - R interval of the first two complexes as compared to the last two complexes. PR: .12 sec, QRS: .08 sec, QT: .44 sec.

Monday, February 23, 2015

Practice EKG Strips 415

Identify the following rhythms.

1.
What initial intervention is appropriate for this pulseless rhythm?











a. Transcutaneous pacing
b. Epinephrine 1 mg IV/IO q 3 - 5 minutes
c. Cardiopulmonary resuscitation
d. Atropine 0.5 mg IV/IO q3 - 5 minutes

2.










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

3.











a. Sinus rhythm with unifocal PVCs
b. Sinus rhythm with trigeminy
c. Sinus rhythm with a triplet of PVCs
d. Sinus rhythm with multiform PVCs

4.













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

5.














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


Answers
1. c. Cardiopulmonary resuscitation

2. b. Demand AV pacing. Looks like 100% ventricular paced with demand atrial pacing. It looks like the ventricular - atrial (V - A) interval The period of time between the ventricular initiated beat and the atrial initiated beat is about .84 sec. Note the difference between the R - R interval of the complexes with the native beats and the R - R interval of the complexes with the dual paced beats.

3. Sinus rhythm with unifocal PVCs.  The rhythm is irregular due to the PVCs.  The rate is 93/min. The P waves are upright and are associated with a QRS complex. There is 1 mm ST depression in lead II.  There are unifocal PVCs seen every 4th beat, quadrigeminy.  A compensatory pause follows each PVC.  PR: .08 sec, QRS: .08 sec, QT: .32 sec.

4. c. Ventricular paced rhythm. The rhythm is regular. The rate is 60 bpm. No P waves are seen. There are pacer spikes seen before each QRS complex.

5. B. Atrial fibrillation.  The rhythm is irregular.  The rate is 40 bpm.  No P waves are seen, fibrillation is seen.  No ectopic beats are present. PR: ---, QRS: .12 sec, QT: .40 sec

Friday, February 20, 2015

Practice EKG Strips 414

Identify the following rhythms.

1.













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

2.














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

3. After experiencing several episodes of this rhythm, the MD orders an Amiodarone drip beginning with a bolus dose. What is the usual loading dose for an Amiodarone infusion?










a. 150 mg IV over 10 minutes
b. 200 mg IV over 10 minutes
c. 250 mg IV over 10 minutes
d. 300 mg IV over 10 minutes

4. A 75 year old arrives to the ER in cardiac arrest. CPR is in progress. He has received two shocks at 200 J and 300 J as well as two doses of epinephrine 1 mg in route. As he is transferred to the stretcher and placed on the monitor, the following rhythm is observed. What medication is indicated in the treatment of this arrhythmia?















a. Vasopressin 40 units IV
b. Procainamide 20 mg/min
c. Magnesium 1 -2 gm IV
d. Amiodarone 150 mg IV

5.











a. Idioventricular rhythm
b. Demand ventricular rhythm
c. Junctional rhythm
d. Atrial paced

Answers
1. c. Ventricular paced rhythm. The rhythm is regular. The rate is 60 bpm. No P waves are seen. There are pacer spikes seen before each QRS complex.

2. b. Atrial fibrillation..  The rhythm is irregular.  The rate is 40 bpm.  No P waves are seen, just some fibrillation between the QRS complexes.  The QRS complexes are narrow.  No ectopic beats are seen. PR: ---, QRS: .08 sec, QT: .44 sec.

3. A. 150 mg IV over 10 minutes. Then 1 mg/min for 6 hours then 0.5 mg/hr for 18 hr

4. c. Magnesium 1 - 2 gm IV.

5. b. Demand ventricular rhythm..  The first complex is ventricular paced.  This is followed by three intrinsic beats.  The rhythm concludes with ventricular paced beats. The native beats show ST-T wave depression.

Thursday, February 19, 2015

Practice EKG Strips 413

Identify the following rhythms.

1.














a. Accelerated junctional rhythm
b. Accelerated idioventricular rhythm
c. First degree heart block
d. Normal sinus rhythm

2.











a. Ventricular tachycardia
b. Ventricular fibrillation
c. Polymorphic ventricular tachycardia
d. Accelerated idioventricular rhythm

3.













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

4.











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

5.










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

Answers
1. a. Accelerated junctional rhythm. The rhythm is regular. The rate is 65 bpm. No P waves are seen. The QRS complexes are narrow. No ectopic beats are seen. PR: ---, QRS: .08 sec, QT: .52 sec

2. a. Ventricular tachycardia. The QRS complexes are fairly uniform

3. b. Ventricular fibrillation. The QRS complexes are too disorganized to be answers A, C, or D. The definitive treatment for this rhythm is defibrillation.

4. b. Complete heart block. The rhythm is slightly irregular. The P waves and the QRS complexes are not paired together. The atrial rate is 100 bpm while the ventricular rate is 35 bpm.

5.  b. Demand AV pacing. Looks like 100% ventricular paced with demand atrial pacing. It looks like the ventricular - atrial (V - A) interval, the period of time between the ventricular initiated beat and the atrial initiated beat is about .84 sec. Note the difference between the R - R interval of the complexes with the native beats and the R - R interval of the complexes with the dual paced beats


Wednesday, February 18, 2015

Practice EKG Strips 412

Identify the following rhythms.

1.Which of the following medications can be used to treat this rhythm:











a. Magnesium 1 -2 g IV/IO
b. Cardizem 0.25 mg/kg IV/IO
c. Epinephrine 1 mg IV/IO
d. Amiodarone 300 mg IV/IO

2. During a cardiac arrest a patient receives a third shock at 300 J. A brief review of the post shock rhythm shows the patient to be in refractory VF. What antiarrhythmic can be given.










 a. Vasopressin 40 units IV/IO
 b. Amiodarone 300 mg IV/IO
 c. Epinephrine 1 mg IV/IO
 d. Sodium bicarbonate 1 mEq/kg IV/IO

3. What is wrong with this picture?











a. It shows failure to capture of polymorphic VT
b. It shows inappropriate pacing of VF
c, It shows inappropriate synchronization of TDP
d. It shows failure to sense during pacing of CHB

4. What is wrong with this picture?






a. It shows appropriate cardioversion of supraventricular tachycardia
b. It shows inappropriate defibrillation of atrial fibrillation
c. It shows appropriate defibrillation of ventricular tachycardia
d. It shows inappropriate cardioversion of polymorphic VT


5.

A 56 year old arrives to the ER with chest pain, shortness of breath, and nausea. He skin is cool and clammy. VS: 98.0-35-28. BP 90/45. Sats: 92%. He is placed on the monitor and the noted to be sinus bradycardia with ST elevation. An IV is started and he is placed on oxygen at 4L/min. Transcutaneous pacing is attempted. You increase the milliamps to 50 milliamps and note the following changes on the monitor. What is the next appropriate intervention?











a. Begin Dopamine at 2 - 20 mcg/kg/min
b. Continue to increase the milliamps
c. Administer atropine 0.5 mg IV/IO
d. Begin nitroglycerine at 5 mcg/min and titrate for chest pain


Answers
1. c. Epinephrine 1 mg IV/IO every 3 - 5 minutes or Vasopressin 40 units once as a first dose or second dose to epinephrine. Investigate the Hs & Ts

2. b. Amiodarone 300 mg IV/IO. May be repeated at 150 mg for refractory VF/VT

3. c. It shows inappropriate synchronization of TDP . Deliver an unsynchronized shock to polymorphic VT

4. b. It shows inappropriate defibrillation of atrial fibrillation

5. b. Continue to increase the milliamps.

Tuesday, February 17, 2015

Practice EKG Strips 411

Identify the following rhythms.

1.














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

2.











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

3.












a. First degree block
b. Sinus tachycardia
c. Sinus rhythm
d. Sinus arrhythmia

4.











a. Sinus rhythm with monofocal PVCs
b. Sinus rhythm with a triplet of PVCs
c. Sinus rhythm with trigeminal PVCs
d. Sinus rhythm with multifocal PVCs


5. What initial intervention is appropriate for this pulseless rhythm?











a. Transcutaneous pacing
b. Epinephrine 1 mg IV/IO q 3 - 5 minutes
c. Cardiopulmonary resuscitation
d. Atropine 0.5 mg IV/IO q3 - 5 minutes.

Answers
1.A. Sinus rhythm with sinus arrest. The rhythm is irregular. The rate is 40 bpm. There are positive P waves that are paired with QRS complexes. The QRS complexes are narrow. No ectopic beats are seen. Ther is ST-T wave depression. A 2.8 second period of sinus arrest follows the 3rd complex. PR: .16 sec, QRS: .08 sec, QT: .40 sec

2.C. Biventricular pacing. The rhythm is regular. The rate is 71 bpm. No P waves are seen. The intrinsic rhythm looks like atrial fibrillation. There are biventricular pacer spikes before each QRS complex. No ectopic beats are seen. PR: ---, QRS: .16 sec, QT: .44 sec.

3. C. Sinus rhythm. Rate 93 bpm Rhythm: regular. P waves are seen with each QRS complex. The QRS complexes are narrow. No ectopic beats are seen. PR: .16 sec, QRS: .08 sec, QT: .38 sec

4. c. Sinus rhythm with trigeminal PVCs. The rhythm is irregular due to the PVCs. There are upright P waves associated with QRS complexes. Unifocal PVCs are seen every third beat, trigeminy. PR: .16 sec, QRS: .12 sec, QT: .40 sec.

5. c. Cardiopulmonary resuscitation.


Monday, February 16, 2015

Practice EKG Strips 410

Identify the following rhythms.

1.











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

2.











a. Atrial pacing
b. AV pacing with biventricular pacing
c. Biventricular pacing
d. Ventricular pacing


3.A 35 year old with a 2 day history of her "heart racing" comes to the ER with shortness of breath and dizziness. She is alert and oriented. VS: 98.2-167-23. BP 107/67. Sats 94% on room air. After placing her on the monitor the following rhythm is seen. An IV is started in her left AV and oxygen at 2 L/min via nasal cannula is started. What is the next appropriate intervention?












a. Give Cardizem 0.35 mg/kg IV
b. Attempt vagal maneuvers
c. Give Adenosine 6 mg IV
d. Cardioversion at 50 J

4.











a. Atrial fibrillation
b. Junctional rhythm
c. Idioventricular rhythm
d. Sinus bradycardia

5.











a. Sinus rhythm with unifocal PVCs
b. Sinus rhythm with trigeminy
c. Sinus rhythm with a triplet of PVCs
d. Sinus rhythm with multiform PVCs


Answers
1. a. Second degree heart block type II.  The PR interval on the conducted beats is the same.  There are dropped or nonconducted P waves seen after each QRS complex.  The P-P interval is consistent. No ectopic beats are noted.

2. b. AV pacing with biventricular pacing.  An atrial spike is seen before each P wave and two pacerspikes are seen before each QRS complex.  No ectopic beats are seen.

3. B. Attempt vagal maneuvers. The patient is only symptomatic st this time.  Let's get ready for the adenosine.

4.b. Junctional rhythm.  The rhythm is regular with a rate of 40 bpm. The QRS complexes are narrow.  No ectopic beats are seen.  PR:--, QRS: .08 sec, QT: .40 sec.

5. a. Sinus rhythm with unifocal PVCs.  t. The underlying rhythm is sinus.  Upright P waves precede a QRS complex.  The QRS complexes are narrow.  Unfocal PVCs are seen every fourth beat. A compensatory pause follows each PVC. PR: .20 sec, QRS: .08 sec, QT: ,36 sec,