Practice EKG Rhythm Strips 134
Identify the following rhythms.
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Answers
1.
The rhythm is irregular because of the PVCs. The calculated rate is 62/min. There are upright P waves with each sinus beat. The PR interval is slightly prolonged. There are unifocal PVCs present. The PVCs have a fusion morphology. Notice the P wave that is buried in the upstroke of the first PVC and the small P wave that precedes the 2nd PVC. PR: .22 sec, QRS: .08 sec, QT: .38 sec.
2.
I put this long strip on so as to be able visualize the variety of different rhythms that are present. The rhythm is irregular because of the frequent unifocal PVCs. The rate is 80/min. There are some upright as well as inverted P waves present. The 2nd, 3rd, 11th, and 12th complexes have inverted P waves while the 5th, 6th, 8th, and 9th complexes have upright P waves. There are unifocal PVCs that occur every 3rd beat, ventricular trigeminy. PR: .12 sec, QRS: .08, QT: .40 sec.
3.
The rhythm is irregular. The rate is 150/min. There are upright P waves present on the sinus beats. The P waves are absent during the run of supraventricular tachycardia (SVT). The QRS complexes are wide on the sinus beats as well as on the QRS complexes during the run of SVT. They both have a similar looking morphology so that is why I call it a run of SVT rather than ventricular tachycardia. You could also refer to it as wide complex tachycardia. PR: .16 sec, QRS: .12 sec, QT: .38 sec. It is acceptable to give adenosine to a patient with a wide complex tachycardia when the morphology of the QRS complexes are unifocal. Perform your primary survey: ABCs. Recognize any symptoms of instability: hypotension, poor end-organ perfusion. EKG: obtain a 12 lead to validate rhythm. Vagal maneuvers; coughing, bearing down, ice water application to the face. Adensoine: 6mg initially followed by 12mg if needed. Intervene electrically: Cardiovert immediately if the patient is unstable. Look to the experts: consider expert consultation for immediate treatment and on going treatment.
4.
The rhythm is irregular. The rate is around 250/min. The 1st complex is a sinus beat but this deteriorates into a polymorphic ventricular tachycardia. If the patient were pulseless you would consider immediate defibrillation. If the patient has a pulse then consider antiarrhythmics: Amiodarone, Lidocaine, or Procainamide. If symptomatic then consider giving an unsynchronized shock at 200 J (biphasic) or 360 (monophasic). Evaluate oxygenation and electrolytes. Evaluate medications that might contribute to prolonged QT intervals. If you look at the 1st complex it appears that the QT interval is very prolonged, about 56 sec. This is based on one complex so you would need to know what the patient's baseline QT was.
5.
The rhythm is regular. The rate is 136/min. There are upright P waves before each QRS complexes. No ectopic beats are seen. PR: .12 sec, QRS: .08 sec, QT: .28 sec.
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4.
5.
Answers
1.
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| 1st degree block with unifocal PVCs |
The rhythm is irregular because of the PVCs. The calculated rate is 62/min. There are upright P waves with each sinus beat. The PR interval is slightly prolonged. There are unifocal PVCs present. The PVCs have a fusion morphology. Notice the P wave that is buried in the upstroke of the first PVC and the small P wave that precedes the 2nd PVC. PR: .22 sec, QRS: .08 sec, QT: .38 sec.
2.
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| Junctional and sinus beats with trigeminal PVCs |
I put this long strip on so as to be able visualize the variety of different rhythms that are present. The rhythm is irregular because of the frequent unifocal PVCs. The rate is 80/min. There are some upright as well as inverted P waves present. The 2nd, 3rd, 11th, and 12th complexes have inverted P waves while the 5th, 6th, 8th, and 9th complexes have upright P waves. There are unifocal PVCs that occur every 3rd beat, ventricular trigeminy. PR: .12 sec, QRS: .08, QT: .40 sec.
3.
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| NSR with run of SVT |
The rhythm is irregular. The rate is 150/min. There are upright P waves present on the sinus beats. The P waves are absent during the run of supraventricular tachycardia (SVT). The QRS complexes are wide on the sinus beats as well as on the QRS complexes during the run of SVT. They both have a similar looking morphology so that is why I call it a run of SVT rather than ventricular tachycardia. You could also refer to it as wide complex tachycardia. PR: .16 sec, QRS: .12 sec, QT: .38 sec. It is acceptable to give adenosine to a patient with a wide complex tachycardia when the morphology of the QRS complexes are unifocal. Perform your primary survey: ABCs. Recognize any symptoms of instability: hypotension, poor end-organ perfusion. EKG: obtain a 12 lead to validate rhythm. Vagal maneuvers; coughing, bearing down, ice water application to the face. Adensoine: 6mg initially followed by 12mg if needed. Intervene electrically: Cardiovert immediately if the patient is unstable. Look to the experts: consider expert consultation for immediate treatment and on going treatment.
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| Polymorphic ventricular tachycardia |
The rhythm is irregular. The rate is around 250/min. The 1st complex is a sinus beat but this deteriorates into a polymorphic ventricular tachycardia. If the patient were pulseless you would consider immediate defibrillation. If the patient has a pulse then consider antiarrhythmics: Amiodarone, Lidocaine, or Procainamide. If symptomatic then consider giving an unsynchronized shock at 200 J (biphasic) or 360 (monophasic). Evaluate oxygenation and electrolytes. Evaluate medications that might contribute to prolonged QT intervals. If you look at the 1st complex it appears that the QT interval is very prolonged, about 56 sec. This is based on one complex so you would need to know what the patient's baseline QT was.
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| Sinus tachycardia |
The rhythm is regular. The rate is 136/min. There are upright P waves before each QRS complexes. No ectopic beats are seen. PR: .12 sec, QRS: .08 sec, QT: .28 sec.
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