Tuesday, March 31, 2015

Sinus Rhythm Quiz

Identify the following sinus rhythms.

1.












a. Sinus arrhythmia
b. Normal sinus rhythm
c. Sinus bradycardia
d. Sinus tachycardia

e. Sinus arrest or pause

2.














a. Sinus arrhythmia
b. Normal sinus rhythm
c. Sinus bradycardia
d. Sinus tachycardia

e. Sinus arrest or pause

3.













a. Sinus arrhythmia
b. Normal sinus rhythm
c. Sinus bradycardia
d. Sinus tachycardia

e. Sinus arrest or pause

4.













a. Sinus arrhythmia
b. Normal sinus rhythm
c. Sinus bradycardia
d. Sinus tachycardia

e. Sinus arrest or pause

5.















a. Sinus arrhythmia
b. Normal sinus rhythm
c. Sinus bradycardia
d. Sinus tachycardia

e. Sinus arrest or pause

6.













a. Sinus arrhythmia
b. Normal sinus rhythm
c. Sinus bradycardia
d. Sinus tachycardia

e. Sinus arrest or pause


7.














a. Sinus arrhythmia
b. Normal sinus rhythm
c. Sinus bradycardia
d. Sinus tachycardia

e. Sinus arrest or pause

8.














a. Sinus arrhythmia
b. Normal sinus rhythm
c. Sinus bradycardia
d. Sinus tachycardia

e. Sinus arrest or pause

9.














a. Sinus arrhythmia
b. Normal sinus rhythm
c. Sinus bradycardia
d. Sinus tachycardia

e. Sinus arrest or pause

10.













a. Sinus arrhythmia
b. Normal sinus rhythm
c. Sinus bradycardia
d. Sinus tachycardia

e. Sinus arrest or pause



Answers

1. The answer is: b. Normal sinus rhythm. The rhythm is regular.  The heart rate is 78.  There are P waves before each QRS complex.  The P waves are biphasic suggesting biatrial enlargement.  The QRS complexes are narrow.  No ectopic beats are noted.  PR. 10 sec, QRS: .08 sec, QT: .28 sec

2. The answer is: d. Sinus tachycardia.  The rhythm is regular with a rate of 136 bpm.  The P waves are uniform and upright.  The QRS complexes are narrow. No ectopic beats are seen.  PR: .12 sec, QRS: .08 sec, QT: .28 sec.

3. The answer is:  e. Sinus arrest or pause.  The rhythm is irregular.  The rate is 30 bpm.  The P waves are small but are uniform and precede each QRS complex.  There is a long is a 2.8 sec pause that follows the first complex.  After the pause sinus rhythm resumes. The QRS complexes are narrow.  No ectopic beats are seen. PR: .16 sec, QRS: .08 sec, QT: .48 sec.

4. The answer is: a. Sinus arrhythmia. The rhythm is irregular and the heart rate is 70 bpm.  With the exception of the first P waves, all the P waves look uniform and are paired up with a QRS complex. The QRS complexes are narrow.  No ectopic beats are seen.  PR: .12 sec, QRS: .08 sec, QT: .40 sec.


5. The answer is: c. Sinus bradycardia.  The rhythm is regular.  The heart rate is extremely slow at 30 bpm. The P waves axis are positive.  The P waves are associated with a QRS complex.  The QRS complexes are wide.  No ectopic beats are seen.  PR: .20 sec, QRS: .16 sec, QT: .44 sec.

6. The answer is: b. Normal sinus rhythm.  The rhythm is regular.  The rate is 93 bpm.  There are small upright P waves that are paired with a QRS complex.  The QRS complexes are wide.  A deep Q wave is seen with the QRS complexes.  This may represent an old or recent infarct.  T wave inversion is seen, this represents ischemia. No ectopic beats are seen. PR: .12 sec, QRS: .12 sec, QT: .36 sec.

7. The answer is: b. Sinus rhythm with a pause.  The rhythm is irregular with a rate of 90 bpm. Uniform, upright P waves are seen before each QRS complex.  A brief .84 sec pause is seen.  The QRS complexes are narrow.  No ectopic beats are present. PR: .18 sec, QRS: .08 sec, QT: .32 sec

8. The answer is: d. Sinus tachycardia.  The rhythm is regular with a rate of 125 bpm.  The P waves are positive and are associated with a QRS complex.  The QRS complexes are narrow.  No ectopic beats are present. PR: .12 sec, QRS: .08 sec, QT: .38 sec.

9. The answer is: d. Sinus bradycardia with sinus arrhythmia.  The rhythm is irregular.  The rate is 60 bpm. The P waves are associated with a QRS complex and are uniform and upright.  The QRS complexes are wide.  There is ST elevation seen in lead II.  No ectopic beats are present.  PR: .20 sec, QRS: .16 sec, QT: .44 sec.

10. The answer is: c. Sinus bradycardia with sinus arrest.  The rhythm is irregular.  The heart rate is 30 bpm.  There are upright and uniform P waves seen before each QRS complex.  The QRS complexes are narrow.  No ectopic beats are seen.  A long period of sinus arrest, about 4 seconds, is seen between the 2nd and 3rd complexes.  PR: .20, QRS: .12 sec, QT: 44 sec.

Monday, March 30, 2015

Practice EKG Strips 440

Identify the following rhythms.

1. Which of the following may be a causative factor related to this rhythm?







a. Respiratory cycle
b. Caffeine ingestion
c. Intraventricular conduction delays
d. Pericarditis


2. During surgery your patient's DDD pacemaker was switched to the VOO mode to provide asynchronous pacing. In the pacemaker codes, what does the third O mean?













a. The chamber that is paced
b. The response of the chamber to the sensed: triggered or inhibited
c. The chamber that sensed
d. The rate modulation of the chamber

3.







a. Sinus rhythm with sinus arrest
b. Sinus rhythm with a PJC
c. Sinus rhythm with a PVC
d. Sinus rhythm with a PAC


4. The AHA suggests that all of the following medications may be routinely administered during an adult VF/VT cardiac arrest EXCEPT:








a. Epinephrine
b. Sodium bicarbonate
c. Vasopressin
d. Amiodarone

5.











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

Answers

1. a. Respiratory cycle

2. b. The response of the chamber to the sensed: triggered or inhibited

3. b. Sinus rhythm with a PJC or two.. The negative or inverted P wave on the ectopic beats indicates that the ectopic beat originated at the level of the AV junction

4. b. Sodium bicarbonate

5.  a. Complete heart block. The P - P interval is very consistent. There is a P wave buried in the QRS so this makes it a complete heart block.

Friday, March 27, 2015

Practice EKG Strips 439

Identify the following rhythms.

1.





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

2.













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

3.








a. Sinus tachycardia with multifocal PVCs
b. Sinus rhythm with multifocal PVCs
c. Supraventricular tachycardia with multifocal PVCs
d. Atrial tachycardia with multifocal PVCs

4.







a. Normal sinus rhythm
b. Junctional rhythm
c. Accelerated idioventricular rhythm
d. Atrial fibrillation

5.  A 78 year old who admitted with calcium channel blocker toxicity and complete heart block is found to have agonal respirations during the night rounds. He is unresponsive to verbal and tactile stimuli. No pulse is detected. A code is called and CPR with positive pressure ventilations are initiated. Which of the following interventions is indicated for this rhythm?








a. Atropine 0.5 mg IV/IO
b. Dopamine 2 - 20 mcg/kg/min
c. Epinephrine 1 mg IV/IO
d. Transcutaneous pacing at 80/min
e. Defibrillation at 200 J


Answers
1. b. Atrial flutter with a PVC thrown in for good measure.

2. a. Multifocal atrial tachycardia. Irregular rhythm. Rate over 100. Three P waves of differing morphology.

3. a. Sinus tachycardia with a PVC. The rhythm is irregular. The rate is 110/min. The P waves are uniform and upright. The PR interval is prolonged. A PVC but actually a fusion beat is seen, the 7th complex. Notice the P wave associated with the PVC. Should not be there. A PVC fired off about the same time as the sinus impulse.

4. c. Accelerated idioventricular rhythm. The rhythm looks regular. The rate is 55 bpm. No P waves are seen. The QRS complexes are wide with an rSR complex seen in lead V1, RBBB. No ectopic beats are seen. PR: ---, QRS: .16 sec, QT: .40 sec.

5. The alogrithm changes from unstable bradycardia to PEA. So use your PEA meds: Epinephrine 1 mg IV/IO or Vasopressin 40 units for PEA. Look for and treat reversible causes. CCB overdose. Give glucagon or calcium choride or gluconate.

Thursday, March 26, 2015

Practice EKG Strips 438

Identify the following rhythms.

1.







a. Sinus bradycardia
b. Idioventricular rhythm
c. Junctional rhythm
d. 2nd degree heart block type I

2.







a. Demand ventricular pacing
b. Demand atrial pacing
c. Failure to sense
d. Failure to capture

3.







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


4.







a. Ventricular paced with bigeminal PVCs
b. Atrial paced with bigeminal PVCs
c. Biventricular paced with bigeminal PVCs
d. Atrial paced with bigeminal PVCs

5.







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



Answers
1. b. Idioventricular rhythm.  Idioventricular is slow and fat qrs's. Junctional slow with small qrs's

2. c. Failure to sense. The pacemaker is firing without sensing the inherent or native heart rhythm. As you can see there are pacespikes that fall on or around the QRS complexes. With failure to capture, the pace spkes will not be immediately followed by a QRS complex.

3.  c. Sinus bradycardia. The rhythm is regular. The heart rate is 50/min. The P waves are uniform and upright. The QRS complexes are narrow. There is some ST depression and T wave inversion present. No ectopic beats are seen. PR: .12 sec, QRS: .08 sec, QT: .40 sec.

4. c. Biventricular paced with bigeminal PVCs. The rhythm is irregular. The rate is about 100/min. Upright P waves are present and they are associated with a QRS complex. Biventricular pacer spikes are seen before the QRS complexes. PVCs are seen every other beat, bigeminy.

5. b. Second degree block type I. The PR interval is getting longer over successive beats. This is followed by a dropped beat. Then the cycle repeats itself.

Wednesday, March 25, 2015

Practice EKG Strips 437

Identify the following rhythms.

1.













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



2.













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

3.













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

4.












a. Sinus bradycardia with a pause
b. Sinus bradycardia with sinus arrhythmia
c. Wenckebach
d. Junctional rhythm

5.












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

Answers
1.b. Atrial fibrillation. The rhythm is irregular, irregular. The rate is extremely bradycardic at 30/min. No P waves are seen. Fibrillation can be seen between the QRS complexes. The QRS complexes are wide. There is 3 mm ST elevation in lead II. No ectopic beats are seen. PR: ---, QRS: .12 sec, QT: .44 sec.

2. b. Biventricular paced. The rate is regular. The rate is 75/min. The P waves are uniform. The rhythm is 100% biventricular paced.

3. a. Junctional tachycardia. The rhythm is regular. The rate is 125/min. No P waves are seen. That notching on the down slope of the ST segment may be an inverted P wave. The QRS complexes are narrow. No ectopic beats are seen. PR: ---, QRS: .08 sec, QT: .36 sec. If the rate were over 150 we would probably call this SVT. It cannot be sinus tachycardia or atrial tachycardia because both rhythms would have upright P waves

4. a. Sinus bradycardia with a pause. The rate is slow, it's 40/min. The rhythm is irregur because of the pause. There are upright and uniform P waves before each QRS complex. The QRS complexes look a little wide. No ectopic beats are seen. There is a 1.6 second pause present. PR: .16 sec, QRS: .12 sec, QT: .40 sec.

5.  b. Multifocal atrial tachycardia. A definite P wave is seen with the 9th complex. Suspicious P waves are seen with the 12th and 17th complexes too.

Tuesday, March 24, 2015

Practice EKG Strips 436

Identify the following rhythms.

1.













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


2.














a. Atria paced
b. Ventricular paced
c. Accelerated idioventricular rhythm
d. Ventricular tachycardia

3.













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

4.













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

5.














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

Answers
1. b. Supraventricular tachycardia. The rate is 150/min. The rhythm is regular. No P waves. The QRS complexes are narrow. No ectopic beats. PR: ---, QRS: .08 sec, QT: .36 sec.

2. b. Ventricular paced. The rhythm is regular. The rate is 71/min. No P waves are seen. 100% ventricular paced.

3.a. Compete heart block.  In the first complex, the PR interval is different than the other two. It is very prolonged. In the remaining two complexes the PR interval is the same. So the rhythm takes on a type II characteristic. There are dropped beats that follow each QRS complex. The atrial rate is 60/min and the ventricular rate is 31/min. The QRS complexes are narrow so the block must be at the level of the AV junction

4. c. Atrial paced. The rhythm looks regular. The rate is 75/min. Pacer spikes are seen before each P wave. The QRS complexes are wide. Some T wave inversion is present. The A-V interval has a prolonged setting of .28 sec. QRS: .12 sec, QT: .44 sec.

5.  a. Junctional rhythm. B is incorrect because the QRS complexes are not wide and the rate is too fast for an idioventricular rhythm. C. is not correct because we do not see any nonconducted P waves. D is not correct because the rhythm is regular and we do not see any fibrillatory activity between the QRS complexes.

Monday, March 23, 2015

Practice EKG Strips 435

Identify the following rhythms.

1. What medications or interventions are indicated for the following rhythm?











a. Atropine and Epinephrine
b. Epinephrine and transcutaneous pacing
c. Defibrillation and Vasopressin
d. Vasopressin and Epinephrine

2. What medications or interventions are indicated for the following rhythm? The patient has a pulse.













a. Atropine 0.5 mg IV and transcutaneous pacing
b. Epinephrine 1mg IV and vasopressin 40 units
c. Adenosine 6mg IV and cardioversion at 50 J
d. Amiodarone and Dopamine at 20 mcg/kg//min

3.











a. Failure to capture
b. Failure to sense
c. Demand ventricular pacing
d. Demand atrial pacing


4.











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

5.













a. First degree block with a pause
b. Sinus arrhythmia
c. Second degree heart block type I
d. Second degree heart block type II

Answers

1. d. Vasopressin and Epinephrine

2. a. Atropine 0.5 mg IV and transcutaneous pacing.  The use of atropine in a third degree block is not completely contraindicated. Recall that a third degree block can occur at various levels: the level of the AV node, the level of the His bundle, or in the distal conduction system. In the strip above the block is at the level of the AV node. You can tell this because the QRS complex is narrow, not wide as when the block occurs lower in the conduction system. The AHA says that the provider should avoid "relying on atropine" when the third degree block is likely to be in the His bundle or more distal conduction system. These blocks are not likely to respond to atropine and are preferably treated with TCP or beta adrenergic agents. However, "atropine may be beneficial in the presence of AV block when the block occurs at the level of the AV node."

3. a. Failure to capture.  Those sense markers (small triangles) will disappear once you obtain electrical capture. With failure to sense the pacer spikes would fall on the QRS complexes or randomly around the QRS complexes.

4. a. Sinus bradycardia with sinus arrest. Some artifact is seen in lead II. Notice that the small artifact before the 2nd complex is missing from the V1 lead. Extreme sinus bradycardia. I doubt that there was much tissue perfusion going on with this rhythm.

5. a. First degree block with a pause. The rhythm is irregular. The rate is 60/min. The P waves are uniform and upright. The PR interval is prolonged. The QRS complex is wide. No ectopic beats are seen. PR: .28 sec, QRS: .10 sec, QT: .40 sec.

Friday, March 20, 2015

Practice EKG Strips 434

Identify the following rhythms.

1.












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

2.









a. NSR with a run of SVT
b. NSR with a run of VT
c. NSR with a run of MAT
d. NSR with a run of AIVR

3. Which of the following medications is NOT indicated to control the rate of this rhythm?











a. Cardizem 0.25mg/kg IV
b. Lidocaine 1 - 1.5 mg/kg IV
c. Metoprolol 5mg IV
d. Verapamil 2.5 - 5mg IV

4.











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

5.











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


Answers
1. c. Junctional rhythm. No P waves are seen. The rate is around 46/min. There is an rSR complex in the V1 lead. So, normally you would probably want to call this an accelerated idioventricular rhythm but in this case the patient has a known RBBB which is the cause of the wide QRS complex.

2. b. NSR with a run of VT

3. b. Lidocaine 1 - 1.5 mg/kg IV is the incorrect dose.

4. c. Torsades de pointes. IV magnesium 1 - 2 gms. Discontinue any meds known to increase the QT interval. If symptomatic: defibrillate at 200 J. You don't attempt synchronized cardioversion on polymorphic VT. If pulseless, defibrillate at 200

5.  b. Biventricular paced. The two pacers pikes are very close together. Much too close for dual pacing. We are trying to resynchronize the depolarization and contraction of the ventricles in order to improve CO.

Thursday, March 19, 2015

Practice EKG Strips 433

Identify the following rhythms.

1.











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

2. In a cardiac arrest, what is the correct dosage for the second dose of Amiodarone used to treat refractory VT?











a. Amiodarone 100 mg
b. Amiodarone 150 mg
c. Amiodarone 200 mg
d. Amiodarone 300 mg

3.











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


4.













a. Sinus rhythm with demand AV pacing
b. Atrial fibrillation with demand AV pacing
c. Complete heart block with demand AV pacing
d. Junctional rhythm with demand AV pacing


5.












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

Answers
1. a. Sinus bradycardia. The rhythm looks regular. The rate is around 55/min. There are P waves before each QRS complex. The P waves are uniform. The QRS complexes are narrow. No ectopic beats are seen. PR: .20 sec, QRS: .08 sec, QT: .40 sec.

2. b. Amiodarone 150 mg.  IV amiodarone affects sodium, potassium, and calcium channels and has α- and β-adrenergic blocking properties. It is the first antiarrhythmic that is considered for treatment of VF or pulseless VT unresponsive to shock delivery, CPR, and vasopressors.  An initial dose of 300 mg IV/IO can be followed by a second dose of 150 mg IV/IO.

3. c. Atrial flutter. The rhythm is regular. The rate is 75/min. There are 3:1 flutter waves present.

4. a. Sinus rhythm with demand AV pacing. The rhythm is 100% ventricular paced. The 5th and 6th complexes have a native P wave present. The QRS complexes look like some kind of fusion beats between an intrinsic QRS complex and a paced QRS complex.

5. c. Junctional rhythm. No P waves are seen. The rate is around 46/min. There is an rSR complex in the V1 lead. So, normally you would probably want to call this an accelerated idioventricular rhythm but in this case the patient has a known RBBB which is the cause of the wide QRS complex.