Arrhythmia Case Studies Module - Baptist Health South Floridacontent.baptisthealth.net/healthstream/Arrhythmia_Case_Studies_with_Rhythm_Assessment...To analyze an ECG tracing, approach

Clinical LearningClinical Learning

Learning ObjectivesLearning Objectives

•• Determine the rhythm (QRSDetermine the rhythm (QRS--QRS and PQRS and P--P)P)

•• Determine the rate (VR and AR)Determine the rate (VR and AR)

•• Assess P wavesAssess P waves

•• Assess PRI (normal PR interval 0.12Assess PRI (normal PR interval 0.12--0.20 seconds)0.20 seconds)

•• Assess the QRS measurement (normal QRS measurement < 0.12 Assess the QRS measurement (normal QRS measurement < 0.12

11

•• Assess the QRS measurement (normal QRS measurement < 0.12 Assess the QRS measurement (normal QRS measurement < 0.12 seconds, < 3 tiny boxes)seconds, < 3 tiny boxes)

•• Assess the QT interval if applicable (normal range in patient with Assess the QT interval if applicable (normal range in patient with normal heart rate is 0.36normal heart rate is 0.36--0.44 seconds)0.44 seconds)

•• Is there anything else unusual about the rhythm?Is there anything else unusual about the rhythm?

•• Name the rhythm and always correlate the rhythm to your patientName the rhythm and always correlate the rhythm to your patient

EightEight--Step Process to Assist You in Interpreting Rhythm Step Process to Assist You in Interpreting Rhythm Strips to Identify the Specific Arrhythmia/DysrhythmiaStrips to Identify the Specific Arrhythmia/Dysrhythmia

Introduction

To analyze an ECG tracing, approach it in a logical and systematic manner. The following is a basic eight-step process that can be used with any ECG tracing. The key to successfully analyzing ECGs is learning the characteristics or features of each normal and abnormal ECG, and then comparing what you see on the ECG tracing to those

22

and abnormal ECG, and then comparing what you see on the ECG tracing to those characteristics.

Some ECG rhythms may be profoundly slow or fast, in which case you should quickly assess the patient for adequate cardiac output. If cardiac output is compromised, immediate treatment is necessary. If an arrhythmia, dysrhythmia or abnormality is present, this finding should always be compared with your complete assessment of the patient. This will determine the significance of the abnormality and assist in any decision regarding a patient treatment.

EightEight--Step Method to Assist You in Interpreting Rhythm Step Method to Assist You in Interpreting Rhythm Strips to Identify the Specific Arrhythmia/DysrhythmiaStrips to Identify the Specific Arrhythmia/Dysrhythmia

Step 1: Determine the rhythm. Is it regular or irregular? Is there a pattern? An irregular rhythm is considered abnormal. The distance between the consecutive P waves should be the same, just as the distance between the consecutive QRS complexes should be the same throughout the tracing. We call these distances the P-P interval and the R-R interval. A set of calipers, a tool used to examine heart rate, rhythm, and intervals, is a good tool to utilize since your eyes can trick you.

Step 2: Determine the rate. Place it into a group first. Is it normal, fast, or slow?

33

Step 2: Determine the rate. Place it into a group first. Is it normal, fast, or slow? We count the QRS complexes to determine the ventricular rate (VR) and the P waves to determine the atrial rate (AR). Normal rate in the adult is 60-100 beats per minute (bpm). Use the rule of 10 for both regular and irregular rhythms. Count the number of QRS complexes in 6 seconds (30 big boxes on standard graph paper) and multiply by 10 to obtain your ventricular rate. Count the number of P wave complexes in 6 seconds and multiple by 10 to obtain your atrial rate. The most accurate method is the calculation by division method. Use the calculation by division method for regular rhythms only. One example of this method: Ventricular rate or atria rate equals 300 divided by the number of large boxes between one R wave and the next R wave,(VR) or one P wave and the next P wave (AR) Each small box counts for 0.2 of a large box, so 4 large boxes and 1 small box, for example, would be 4.2 large boxes. In this example the ventricular and atrial rate would be 300 divided by 4.2 or 71 bpm. There are various methods but select one that works for you.


Step 3: Assess the P waves. Is there a uniform P wave preceding each QRS complex? Do they appear normal? The P wave is the first waveform, at the start of the cardiac cycle. It begins with its movement away from the baseline and ends on its return to the baseline. We look at the location and morphology (configuration and deflection). Is there a P wave preceding each QRS complex? Are there any P waves without a QRS complex? Abnormal P waves are those that look different, are inverted, absent, follow the QRS complex, or when P waves are not followed by a QRS complex. The normal p wave duration is typically 0.06 to 0.10 seconds (60 msec to 100 msec) in duration (width).

44

Step 4: Assess and measure the PR intervals. Are the PR intervals identifiable? Within normal limits? Constant in duration? The PR interval is the distance from the beginning of the P wave to the beginning of the QRS complex (R wave if the Q wave is absent). The PR interval denotes depolarization of the heart from the SA node through the atria, AV node, and His-Purkinje system. A normal PR interval indicates the impulse originated from the SA node (or close to it) and traveled through the atria and AV node in a regular and unobstructed course. The normal PR interval duration is 0.12 to 0.20 seconds and tells us we have normal conduction.


Step 5: Assess & measure the QRS complexes. Are the QRS complexes within normal limits and appear normal? Are they narrow or wide? A supraventricular rhythm is identified by a narrow QRS.

The QRS is the waveform immediately following P wave and the PR segment. The QRS starting point is where the first wave of the complex starts to move away (sharply or gradually) from the baseline. The QRS complex ends at the point where the last wave of the complex starts to flatten (sharply or gradually) at, above, or below the baseline.

55

(sharply or gradually) at, above, or below the baseline.

The QRS is much bigger than the P wave because depolarization of the ventricles involves considerably larger muscle mass than depolarization of the atria. The QRS complex characteristically looks thinner than the other parts of the ECG because the ventricles depolarize so fast. Determining where the QRS complex ends, can be difficult as you don’t always see a clear transition with nice, straight, lines.

In some ECG tracings you have to use your best educated guess and common sense to conclude what is the duration of the QRS complex. The normal QRS duration is typically less than 0.12 seconds (120 msec) in duration (width).


Step 6: Assess the QT interval. Is it in the normal range? In patients with a normal heart rate, the normal range for QT interval is 0.36-0.44 seconds (360-440 msec). Remember that the QT interval is from the beginning of the QRS complex to the end of the T wave. Excessive QTc interval prolongation in the right setting can be proarrhythmic and degenerate into a potentially fatal ventricular tachyarrhythmia. Because the actually measured QT interval changes with the heart beat in the absence of any intervention, it is usual to correct the measured interval for changes (RR interval) to derive a rate-corrected (QTc) interval, which is then used when evaluating the effect of

66

derive a rate-corrected (QTc) interval, which is then used when evaluating the effect of an intervention.

Step 7: Is there anything else unusual about the rhythm?

Step 8: Name the rhythm. Here we put it all together to determine whether the rhythm is normal sinus rhythm or something else.

.

Directions for Guided Practice Directions for Guided Practice

• Now you will have the opportunity to practice interpreting the following 150 six-second rhythm strips.

• Approach each rhythm systematically using the 8-Step Process.

• Each presented rhythm strip has one or more measurements missing. Stop and write down the correct missing items.

•

77

• Try to be as precise as possible, but your answers may not match exactly. What is critical is that your rhythm identification (interpretation or naming the rhythm) should be exact.

• Following each rhythm strip is the correct answer for you to check your learning.

• Practice makes perfect so good luck and have a great journey as you build your expertise in rhythm interpretation.

Directions for Guided Practice Directions for Guided Practice A set of calipers is the preferred tool for measuring rhythm strips. When measuring on a monitor without electronic calipers, defer to using a plain straight edged paper.

Hold the paper under the baseline or isoelectric line to measure the rate, rhythm, and intervals of the waves by marking them with a pencil.

You will need to move the paper to the next wave to check whether the rhythm is regular or irregular. The rhythm below is an example of being irregular.

88

Rhythm IdentificationRhythm IdentificationThis rhythm strip is from an 86This rhythm strip is from an 86--yearyear--old female complaining of chest pain that old female complaining of chest pain that she rates a 4 on a scale of 0 to 10. Blood pressure: 142/72.she rates a 4 on a scale of 0 to 10. Blood pressure: 142/72.

99

Identify the missing measurement for rhythm interpretation.

Ventricular rate/rhythm 60 bpm/regular

Atrial rate/rhythm 60 bpm/regular

PR interval 0.20 sec

QRS duration ?

Identification ?

Here is the missing measurement for rhythm interpretation.

This rhythm strip is from an 86This rhythm strip is from an 86--yearyear--old female complaining of chest pain that old female complaining of chest pain that she rates a 4 on a scale of 0 to 10. Blood pressure: 142/72.she rates a 4 on a scale of 0 to 10. Blood pressure: 142/72.

1010




QRS duration 0.06 sec

Identification Normal Sinus Rhythm (NSR) using rule of 10

Rhythm IdentificationRhythm Identification


1111

Ventricular rate/rhythm 110 bpm/min (sinus beats)/

regular except for the event

Atrial rate/rhythm 110 bpm/min (sinus beats)/


PR interval 0.20 seconds

QRS duration 0.08 to 0.10 sec

Identification ?


Here are the missing measurement for rhythm interpretation.

1212







Identification Sinus rhythm with two PJCs

Rhythm IdentificationRhythm IdentificationThis rhythm strip is from an 83-year-old female with syncope.


1313

Ventricular rate/rhythm ?


PR interval Lengthening of each PRI


Identification ?


This rhythm strip is from an 83-year-old female with syncope.


1414

Ventricular rate/rhythm 50 bpm/irregular


PR interval Lengthening


Identification Second-degree AV block, Type I (or) Mobitz I (or) Wenckebach

All acceptable terms


Rhythm IdentificationRhythm IdentificationThis rhythm strip is from an 86This rhythm strip is from an 86--yearyear--old female who experienced a old female who experienced a cardiopulmonary arrest. The initial rhythm on the monitor was asystole. The cardiopulmonary arrest. The initial rhythm on the monitor was asystole. The following rhythm resulted after IV administration of epinephrine I mg IVP.following rhythm resulted after IV administration of epinephrine I mg IVP.

1515



Atrial rate/rhythm ?

PR interval None


Identification ?


This rhythm strip is from an 86This rhythm strip is from an 86--yearyear--old female who experienced a old female who experienced a cardiopulmonary arrest. The initial rhythm on the monitor was asystole. The cardiopulmonary arrest. The initial rhythm on the monitor was asystole. The following rhythm resulted after IV administration of epinephrine 1mg IVP.following rhythm resulted after IV administration of epinephrine 1mg IVP.

1616


Atrial rate/rhythm None

PR interval None


Identification Idioventricular rhythm (IVR). This is also called a ventricular escape rhythm.



This rhythm strip is from a 69This rhythm strip is from a 69--yearyear--old man complaining of shortness of breath. old man complaining of shortness of breath. Lung sounds reveal bilateral rales. Blood pressure: 160/58.Lung sounds reveal bilateral rales. Blood pressure: 160/58.

1717


Ventricular rate/rhythm 100-110 bpm (sinus beats)/

Regular except for the events

Atrial rate/rhythm 100-110 bpm (sinus beats)/


PR interval ?

QRS duration 0.08 sec (sinus beats)

Identification ?


Here is the missing measurement and rhythm interpretation.

This rhythm strip is from a 69This rhythm strip is from a 69--yearyear--old man complaining of shortness of breath. old man complaining of shortness of breath. Lung sounds reveal bilateral rales. Blood pressure: 160/58.Lung sounds reveal bilateral rales. Blood pressure: 160/58.

1818





PR interval 0.20 sec (sinus beats)


Identification Sinus tachycardia with uniform PVCs (2)


Identify the missing measurement(s) for rhythm interpretation.

1919





Identification ?

Here is the missing measurement(s) for rhythm interpretation.

2020





Identification Sinus rhythm with first-degree AV block



2121

Ventricular rate/rhythm 210 bpm (using the 6-sec method)/regular

Atrial rate/rhythm Unable to determine

PR interval Unable to determine

QRS duration ?

Identification ?



2222




QRS duration 0.14-.16 sec (difficult to identify beginning and end but definitely wide)

Identification Ventricular tachycardia (monomorphic)



2323


Atrial rate/rhythm Unable to determine for both rhythms

PR interval Unable to determine for both rhythms

QRS duration 0.14 to 0.16 sec in first section and 0.06 sec in second section

Identification ?

Ventricular rate/rhythm 240 bpm (VT) to 75-150 bpm (atrial


2424

Ventricular rate/rhythm 240 bpm (VT) to 75-150 bpm (atrial fib)/ Irregular



QRS duration 0.14 to 0.16 sec (VT) to 0.06 sec (atrial fib)

Identification Monomorphic VT to atrial fibrillation




2525



PR interval Unable to determine-no p waves only flutter waves


Identification ?


2626





Identification Atrial flutter



2727



PR interval None-Varying lengths without any relationship


Identification ?


2828



PR interval None-no relationship


Identification Complete (third-degree) AV block

Rhythm IdentificationRhythm IdentificationThis rhythm strip is from a 52This rhythm strip is from a 52--yearyear--old man found unresponsive, old man found unresponsive, apneicapneic, and , and pulseless upon entering his room. Is there electrical activity on this strip?pulseless upon entering his room. Is there electrical activity on this strip?

2929


Ventricular rate/rhythm 85-90 bpm/regular


PR interval None


Identification ?


This rhythm strip is from a 52This rhythm strip is from a 52--yearyear--old man found unresponsive, old man found unresponsive, apneicapneic, , and pulseless upon entering his room.and pulseless upon entering his room.

3030



PR interval None


Identification Accelerated idioventricular rhythm (AIVR)





3131


Regular except for the two event(s)



PR interval ?


Identification ?



3232







Identification Sinus rhythm with first-degree AV block and two PACs



3333





Identification ?


3434


Atrial rate/rhythm 180 bpm/regular-not all visible



Identification Second-degree AV block type II



3535

Atrial paced activity? ?

Ventricular paced activity? Yes

Paced rate 70

Identification ?


3636

Atrial paced activity? Yes


Paced rate 70

Identification 100% paced rhythm –dual pacemaker


Rhythm IdentificationRhythm IdentificationThese rhythm strips are from a 78These rhythm strips are from a 78--yearyear--old man complaining of shortness of old man complaining of shortness of breath. He has a history of COPD, coronary artery disease, and hypertension.breath. He has a history of COPD, coronary artery disease, and hypertension.

3737






Identification ?


These rhythm strips are from a 78These rhythm strips are from a 78--yearyear--old man complaining of shortness of old man complaining of shortness of breath. He has a history of COPD, coronary artery disease, and hypertension.breath. He has a history of COPD, coronary artery disease, and hypertension.

3838





Identification Atrial fibrillation (controlled VR)


Rhythm IdentificationRhythm IdentificationThis rhythm strip is from a 97This rhythm strip is from a 97--yearyear--old female after a fall.old female after a fall.


3939






Identification ?


This rhythm strip is from a 97This rhythm strip is from a 97--yearyear--old female after a fall.old female after a fall.

4040





Identification Sinus rhythm with first-degree AV block



This rhythm strip is from a 70This rhythm strip is from a 70--yearyear--old man complaining of a sharp old man complaining of a sharp pain across his shoulders. Blood pressure: 218/86.pain across his shoulders. Blood pressure: 218/86.

4141



Regular except for the two events



PR interval ?


Identification ?


This rhythm strip is from a 70This rhythm strip is from a 70--yearyear--old man complaining of a sharp old man complaining of a sharp pain across his shoulders. Blood pressure: 218/86.pain across his shoulders. Blood pressure: 218/86.

4242







Identification Sinus tachycardia with uniform PVCs (two)

Rhythm IdentificationRhythm IdentificationThis rhythm strip is from a 76This rhythm strip is from a 76--yearyear--old man complaining of indigestion.old man complaining of indigestion.


4343




PR interval None


Identification ?


This rhythm strip is from a 76This rhythm strip is from a 76--yearyear--old man complaining of indigestion. old man complaining of indigestion.

4444



PR interval None


Identification Junctional bradycardia

Rhythm IdentificationRhythm IdentificationThis rhythm strip is from an 80This rhythm strip is from an 80--yearyear--old female complaining of weakness.old female complaining of weakness.


4545


Atrial paced activity? No


Paced interval rate ?

Identification ?


This rhythm strip is from an 80This rhythm strip is from an 80--yearyear--old female complaining of weakness.old female complaining of weakness.

4646



Paced interval rate 80

Identification 100% ventricular paced rhythm





Regular except for the event (every other

4747

Regular except for the event (every other beat is an ectopic beat)



PR interval ?

QRS duration 0.08 to 0.10 sec (sinus beats)

Identification ?


Regular except for the event (every other


4848






Identification Sinus bradycardia with ventricular bigeminy

Rhythm IdentificationRhythm IdentificationThis rhythm strip is from a 90This rhythm strip is from a 90--yearyear--old female complaining of hip old female complaining of hip pain after a fall. pain after a fall.

4949



Atrial rate/rhythm 70-75 bpm/regular

PR interval ?


Identification ?


This rhythm strip is from a 90This rhythm strip is from a 90--yearyear--old female complaining of old female complaining of hip pain after a fall. hip pain after a fall.

5050





Identification Normal sinus rhythm


Rhythm IdentificationRhythm IdentificationThis rhythm strip is from a 78This rhythm strip is from a 78--yearyear--old man complaining of palpitations. Note old man complaining of palpitations. Note the point at which the patient was defibrillated.the point at which the patient was defibrillated.

5151



Atrial rate/rhythm 80 bpm (sinus beats)/ Irregular (sinus beats)



Identification ?


This rhythm strip is from a 78This rhythm strip is from a 78--yearyear--old man complaining of palpitations. Note old man complaining of palpitations. Note the point at which the patient was defibrillated.the point at which the patient was defibrillated.

5252

Ventricular rate/rhythm 180 bpm (first 4 beats)/ regular

Atrial rate/rhythm 80 bpm (visible regular sinus beats)



Identification Monomorphic ventricular tachycardia –shock – ventricular beats – sinus rhythm (2 beats at the end of strip)



5353


Regular except for the event




QRS duration ?

Identification ?



5454







Identification Sinus rhythm with uniform PVCs (two)



5555





PR interval ?


Identification ?


5656







Identification Sinus tachycardia with PACs (two)

Rhythm IdentificationRhythm IdentificationThis rhythm strip is from a 20 year old girl who had an altered level of This rhythm strip is from a 20 year old girl who had an altered level of responsiveness. She was limp with a respiratory rate of 8 breaths/min. Blood responsiveness. She was limp with a respiratory rate of 8 breaths/min. Blood sugar was 174.sugar was 174.

5757




PR interval 0.12 to 0.16 sec


Identification ?


This rhythm strip is from a 20 year old girl who had an altered level of This rhythm strip is from a 20 year old girl who had an altered level of responsiveness. She was limp with a respiratory rate of 8 breaths/min. Blood responsiveness. She was limp with a respiratory rate of 8 breaths/min. Blood sugar was 174.sugar was 174.

5858





Identification Sinus tachycardia with an interpolated PVC-does not offset the rhythm


Rhythm IdentificationRhythm IdentificationThis rhythm strip is from an 83This rhythm strip is from an 83--yearyear--old man complaining of chest pain. He had a old man complaining of chest pain. He had a new pacemaker implanted 5 days ago. His blood pressure is 148/60.new pacemaker implanted 5 days ago. His blood pressure is 148/60.

5959




PR interval ?


Identification ?


This rhythm strip is from an 83This rhythm strip is from an 83--yearyear--old man complaining of chest pain. He had a old man complaining of chest pain. He had a new pacemaker implanted 5 days ago. His blood pressure is 148/60.new pacemaker implanted 5 days ago. His blood pressure is 148/60.

6060







Rhythm IdentificationRhythm IdentificationThis rhythm strip is from a 52This rhythm strip is from a 52--yearyear--old man with substernal chest pain. He old man with substernal chest pain. He has a history of COPD and mitral valve regurgitation. Blood pressure: 140/78. has a history of COPD and mitral valve regurgitation. Blood pressure: 140/78.

6161




PR interval ?


Identification ?

This rhythm strip is from a 52This rhythm strip is from a 52--yearyear--old man with substernal chest pain. He old man with substernal chest pain. He has a history of COPD and mitral valve regurgitation. Blood pressure: 140/78. has a history of COPD and mitral valve regurgitation. Blood pressure: 140/78.


6262







Identify the missing measurement and rhythm interpretation.

6363




QRS duration ?

Identification ?


6464





Identification Second Degree AV Block 2:1

Untypeable



6565



PR interval Lengthens before the QRS is dropped or until P wave is nonconducted


Identification ?


6666



PR interval Lengthens before the QRS is dropped or until p wave is nonconducted


Identification 2° AV block, Type I (or) Mobitz I (or) Wenckebach—all acceptable terms



6767



PR interval None


Identification ?


6868



PR interval None


Identification Accelerated junctional rhythm



6969


Atrial rate/rhythm Unable to determine due to quivering baseline

PR interval Unable to determine since no discernible p wave

QRS duration ?

Identification ?



7070






By definition a ventricular rate of 100 or less is considered to be ‘controlled’



7171

Ventricular rate/rhythm None


PR interval None

QRS duration None

Identification ?


7272



PR interval None

QRS duration None

Identification Asystole or Ventricular Asystole



7373




Identification ?


7474





Rhythm Rhythm IdentificationIdentification

These rhythm strips are from a These rhythm strips are from a 4646--yearyear--old female complaining old female complaining of abdominal pain.of abdominal pain.


7575

and rhythm interpretation.


Regular except for the two obvious events



PR interval ?


Identification ?


These rhythm strips are from a These rhythm strips are from a 4646--yearyear--old female complaining old female complaining of abdominal pain.of abdominal pain.

7676







Identification Sinus rhythm with unifocal PVCs (two) and sinus tachycardia

Rhythm IdentificationRhythm IdentificationThis This rhythm strip is from a 30 yearrhythm strip is from a 30 year--old female after a 3old female after a 3--minute seizureminute seizure


7777






Identification ?

This rhythm strip is from a 30 yearThis rhythm strip is from a 30 year--old female after a 3old female after a 3--minute minute seizure. seizure.

7878





Identification Sinus tachycardia




7979



PR interval Varies


Identification ?


8080



PR interval Varies


Identification Complete Heart Block (or) 3°AV block (3°AVB) (or) AV dissociation


Rhythm IdentificationRhythm IdentificationThis rhythm strip is from a 72This rhythm strip is from a 72--yearyear--old man complaining of chest pain. old man complaining of chest pain.


8181





Identification ?

This rhythm strip is from a 72This rhythm strip is from a 72--yearyear--old man complaining of chest pain. old man complaining of chest pain.

8282






Rhythm IdentificationRhythm IdentificationThis rhythm strip is from a 77This rhythm strip is from a 77--yearyear--old female with a congested cough. old female with a congested cough.

8383


Ventricular rate/rhythm 200 to 110 bpm/therefore irregular




Identification ?


This rhythm strip is from a 77This rhythm strip is from a 77--yearyear--old female with a congested cough. old female with a congested cough.

8484

Ventricular rate/rhythm 200 to 110 bpm/ therefore irregular




Identification Atrial fibrillation (uncontrolled VR)



8585

Ventricular rate/rhythm

?

Atrial rate/rhythm None (junctional beats) then 58 bpm (sinus beats)/

None (junctional beats) to regular (sinus beats)

PR interval None (junctional beats) to 0.18 (sinus beats)

QRS duration 0.04 sec (junctional beats) to 0.08 (sinus beats)

Identification ?

Ventricular 30 bpm (junctional beats) to 56 bpm (sinus beats)/


8686


30 bpm (junctional beats) to 56 bpm (sinus beats)/

Irregular (junctional beats) to regular (sinus beats)

Atrial rate/rhythm None (junctional beats) to 58 bpm (sinus beats)/

None (junctional beats) to regular (sinus beats)

PR interval None (junctional beats) to 0.18 (sinus beats)

QRS duration 0.04 sec (junctional beats) to 0.08 (sinus beats)

Identification Junctional bradycardia to sinus bradycardia



8787

Ventricular rate/rhythm 80 bpm (sinus beats)/regular

Atrial rate/rhythm 80 bpm (sinus beats)/regular

PR interval ?


Identification ?


8888

Ventricular rate/rhythm 80 bpm (sinus beats)/regular

Atrial rate/rhythm 80 bpm (sinus beats)/regular



Identification Begins with Atrial flutter then sinus arrest then sinus rhythm



8989

Ventricular rate/rhythm 100 bpm (sinus beats)/

Regular except for the two event

Atrial rate/rhythm 100 bpm (sinus beats)/

Regular except for the two event

PR interval ?


Identification ?



9090







Identification Sinus rhythm with unifocal PVCs (two)

Rhythm IdentificationRhythm IdentificationThis rhythm strip is from a 54This rhythm strip is from a 54--yearyear--old man who had a syncopal episode. old man who had a syncopal episode.


9191






Identification ?


9292





Identification Sinus bradycardia using calculation by division method

Rhythm IdentificationRhythm IdentificationThis rhythm strip is from a 66This rhythm strip is from a 66--yearyear--old man complaining of chest pain. old man complaining of chest pain. Blood pressure: 170/96.Blood pressure: 170/96.

9393





QRS duration ?

Identification ?


This rhythm strip is from a 66This rhythm strip is from a 66--yearyear--old man complaining of chest pain. old man complaining of chest pain.

Blood pressure: 170/96. Blood pressure: 170/96.

9494





Identification Sinus tachycardia with

first-degree AV block


Rhythm IdentificationRhythm IdentificationThis rhythm strip is from a 43This rhythm strip is from a 43--yearyear--old female complaining of palpitations.old female complaining of palpitations.


9595






Identification ?


This rhythm strip is from a 43This rhythm strip is from a 43--yearyear--old female complaining of palpitations. old female complaining of palpitations.

9696





Identification Narrow-QRS tachycardia


Rhythm IdentificationRhythm IdentificationA 43A 43--yearyear--old female is complaining of palpitations. The patient has a history of old female is complaining of palpitations. The patient has a history of SVT and states she cannot tolerate adenosine. The following rhythm is observed SVT and states she cannot tolerate adenosine. The following rhythm is observed on the cardiac monitor after diltiazem IV administration.on the cardiac monitor after diltiazem IV administration.

9797



Atrial rate/rhythm Unable to determine except for the two sinus beats

PR interval Unable to determine except for the two sinus beats

QRS duration 0.08 sec (beginning from third complex)

Identification ?

A 43A 43--yearyear--old woman is complaining of palpitations. The patient has a history of old woman is complaining of palpitations. The patient has a history of SVT and states she cannot tolerate adenosine. The following rhythm is observed SVT and states she cannot tolerate adenosine. The following rhythm is observed on the cardiac monitor after diltiazem administration.on the cardiac monitor after diltiazem administration.


9898

Ventricular rate/rhythm 180 bpm starting from third complex/

Regular (starting from third complex)

Atrial rate/rhythm Unable to determine except for two sinus beats

PR interval Unable to determine except for two sinus beats

QRS duration 0.08 sec (beginning from third complex)

Identification Junctional escape beat to sinus rhythm to narrow-QRS tachycardia




9999




QRS duration Unable to determine, chaotic

Identification ?


100100

Ventricular rate/rhythm Unable to determine



QRS duration Unable to determine, chaotic

Identification Ventricular fibrillation (coarse); the amplitude determines whether something is coarse or fine



101101





Identification ?


102102





Identification 2 AVB, 2:1 conduction (untypeable)



103103




QRS duration ?

Identification ?


104104





Identification Sinus bradycardia with first-degree AV block, wide-QRS (probable bundle branch block)

Rhythm IdentificationRhythm IdentificationThis rhythm strip is from a 76This rhythm strip is from a 76--yearyear--old female complaining of back pain. Her old female complaining of back pain. Her medical history includes a myocardial infarction 2 years ago.medical history includes a myocardial infarction 2 years ago.

105105





Identification ?


This rhythm strip is from a 76This rhythm strip is from a 76--yearyear--old female complaining of back pain. old female complaining of back pain. Her medical history includes a myocardial infarction 2 years ago.Her medical history includes a myocardial infarction 2 years ago.

106106








This rhythm strip is from an 80This rhythm strip is from an 80--yearyear--old man, history of SSS requiring permanent old man, history of SSS requiring permanent

pacemaker, found sitting in a chair. He is unresponsive, pacemaker, found sitting in a chair. He is unresponsive, apneicapneic, and , and pulselesspulseless..

107107




PR interval None

QRS duration None

Identification ?


This rhythm strip is from an 80This rhythm strip is from an 80--yearyear--old man, history or SSS requiring permanent old man, history or SSS requiring permanent

pacemaker, found sitting in a chair. He is unresponsive, pacemaker, found sitting in a chair. He is unresponsive, apneicapneic, and , and pulselesspulseless..

108108



PR interval None

QRS duration None

Identification Asystole – the electrical activity shown is caused by pacemaker spikes from the patient’s permanent pacemaker (no electrical capture on strip)




This rhythm strip is from an 88This rhythm strip is from an 88--yearyear--old female complaining of hip pain old female complaining of hip pain after a fall injury.after a fall injury.

109109






Identification ?


This rhythm strip is from an 88This rhythm strip is from an 88--yearyear--old female complaining of hip pain after a old female complaining of hip pain after a fall injury.fall injury.

110110

Ventricular rate/rhythm 80 bpm using rule of 10/irregular








111111

Ventricular rate/rhythm 40 to 68 bpm/irregular


PR interval Lengthens


Identification ?


112112

Ventricular rate/rhythm 68 to 40 bpm/irregular

Atrial rate/rhythm 68 bpm/regular (first 4 complexes)

PR interval Lengthens


Identification 2° AV block Type I (with a ventricular escape beat at the end)



113113


Ventricular rate/rhythm 50 bpm (junctional beats)/ though irregular-pacemaker site varies


PR interval Unable to determine (junctional beats)


Identification ?


114114

Ventricular rate/rhythm 50 bpm (junctional beats)/ regular

Atrial rate/rhythm Unable to determine (junctional beats)

PR interval Unable to determine (junctional beats)


Identification Sinus bradycardia with a first-degree AV block (where PRI is present) to junctional escape rhythm

Rhythm IdentificationRhythm IdentificationThis rhythm strip is from a 67This rhythm strip is from a 67--yearyear--old female found unresponsive on the side old female found unresponsive on the side of the road. Outdoor temperature is 112of the road. Outdoor temperature is 112°°F. Blood pressure: 238/110, F. Blood pressure: 238/110, respiratory rate: 60/min.respiratory rate: 60/min.

115115




PR interval ?


Identification ?


This rhythm strip is from a 67This rhythm strip is from a 67--yearyear--old female found unresponsive on the side old female found unresponsive on the side of the road. Outdoor temperature is 112of the road. Outdoor temperature is 112°°F. Blood pressure: 238/110, F. Blood pressure: 238/110, respiratory rate: 60/min.respiratory rate: 60/min.

116116









This rhythm strip is from an 84This rhythm strip is from an 84--yearyear--old man complaining of dizziness. He old man complaining of dizziness. He had a triple bypass 4 days ago.had a triple bypass 4 days ago.

117117



60 bpm (sinus beats)/Regular except for the event (every other beat is an ectopic beat)




QRS duration ?

Identification ?

This rhythm strip is from an 84This rhythm strip is from an 84--yearyear--old man complaining of dizziness. He old man complaining of dizziness. He had a triple bypass 4 days ago.had a triple bypass 4 days ago.

118118



60 bpm (sinus beats)/Regular except for the event (every other beat is an ectopic beat)

Atrial rate/rhythm 60 bpm (sinus beats)/ Regular except for the event



Identification Sinus rhythm with ventricular bigeminy

This rhythm strip is from an 81This rhythm strip is from an 81--yearyear--old female with an altered level of old female with an altered level of responsiveness. blood pressure: 160/70, blood sugar: 114.responsiveness. blood pressure: 160/70, blood sugar: 114.


119119





Identification ?


This rhythm strip is from an 81This rhythm strip is from an 81--yearyear--old female with an altered level of old female with an altered level of responsiveness. blood pressure: 160/70, blood sugar: 114.responsiveness. blood pressure: 160/70, blood sugar: 114.

120120





Identification Sinus bradycardia with first-degree AV block


This rhythm strip is from a 80This rhythm strip is from a 80--yearyear--old female who was playing Bingo when old female who was playing Bingo when she felt dizzy and slumped over in her chair. Bystanders state she was she felt dizzy and slumped over in her chair. Bystanders state she was unresponsive for approximately 5 minutes. A pulse is present.unresponsive for approximately 5 minutes. A pulse is present.


121121





Identification ?


This rhythm strip is from a 80This rhythm strip is from a 80--yearyear--old female who was playing Bingo when old female who was playing Bingo when she felt dizzy and slumped over in her chair. Bystanders state she was she felt dizzy and slumped over in her chair. Bystanders state she was unresponsive for approximately 5 minutes. A pulse is present.unresponsive for approximately 5 minutes. A pulse is present.

122122







Rhythm IdentificationRhythm IdentificationThis rhythm strip is from a 91This rhythm strip is from a 91--yearyear--old female complaining of chest pain and old female complaining of chest pain and

difficulty breathing. difficulty breathing.

123123






Identification ?

This rhythm strip is from a 91This rhythm strip is from a 91--yearyear--old female complaining of chest pain and old female complaining of chest pain and

difficulty breathing. difficulty breathing.

124124






Identification Atrial fibrillation

Rhythm IdentificationRhythm IdentificationThis rhythm strip is from an 85This rhythm strip is from an 85--yearyear--old female complaining of numbness in her legs. old female complaining of numbness in her legs.

125125






Identification ?

This rhythm strip is from an 85This rhythm strip is from an 85--yearyear--old female complaining of numbness in her legs. old female complaining of numbness in her legs.

126126






Identification Sinus bradycardia

Rhythm IdentificationRhythm IdentificationThis rhythm strip is from a 59This rhythm strip is from a 59--yearyear--old female who complained of sudden old female who complained of sudden weakness in her legs and fell to the floor in her kitchen.weakness in her legs and fell to the floor in her kitchen.

127127





Identification ?


This rhythm strip is from a 59This rhythm strip is from a 59--yearyear--old female who complained of sudden old female who complained of sudden weakness in her legs and fell to the floor in her kitchen.weakness in her legs and fell to the floor in her kitchen.

128128







Rhythm IdentificationRhythm IdentificationThis rhythm strip is from an 82This rhythm strip is from an 82--yearyear--old female with vomiting x 2 days.old female with vomiting x 2 days.

129129




QRS duration ?

Identification ?


This rhythm strip is from an 82This rhythm strip is from an 82--yearyear--old female with vomiting x 2 days.old female with vomiting x 2 days.

130130







Rhythm IdentificationRhythm IdentificationThis rhythm strip is from a 62This rhythm strip is from a 62--yearyear--old female complaining of chest pain. old female complaining of chest pain. Her blood pressure is 146/104, respirations are 20. Breath sounds are clear.Her blood pressure is 146/104, respirations are 20. Breath sounds are clear.

131131




QRS duration ?

Identification ?


This rhythm strip is from a 62This rhythm strip is from a 62--yearyear--old female complaining of chest pain. old female complaining of chest pain. Her blood pressure is 146/104, respirations are 20. Breath sounds are clear.Her blood pressure is 146/104, respirations are 20. Breath sounds are clear.

132132





Identification Narrow-QRS tachycardia (SVT)


Rhythm IdentificationRhythm IdentificationThis rhythm strip is from a 26This rhythm strip is from a 26--yearyear--old male immediately after a seizure.old male immediately after a seizure.

133133


Atrial rate/rhythm 90 bpm/irregular

PR interval ?


Identification ?


This rhythm strip is from a 26This rhythm strip is from a 26--yearyear--old male immediately after a seizure.old male immediately after a seizure.

134134


Atrial rate/rhythm 90 bpm/irregular



Identification Sinus arrhythmia


Rhythm IdentificationRhythm IdentificationThis rhythm strip is from a 76This rhythm strip is from a 76--yearyear--old man who was playing golf and old man who was playing golf and experienced a syncopal episode.experienced a syncopal episode.

135135




QRS duration ?

Identification ?


This rhythm strip is from a 76This rhythm strip is from a 76--yearyear--old man who was playing golf and old man who was playing golf and experienced a syncopal episode.experienced a syncopal episode.

136136







Rhythm IdentificationRhythm IdentificationThese rhythm strips are from a 44These rhythm strips are from a 44--yearyear--old female complaining of chest pain.old female complaining of chest pain.

137137



PR interval ?


Identification ?


These rhythm strips are from a 44These rhythm strips are from a 44--yearyear--old female complaining of chest pain.old female complaining of chest pain.

138138



PR interval None


Identification Monomorphic ventricular tachycardia




139139



PR interval ?


Identification ?



140140



PR interval Varies


Identification Complete heart block (3rd Degree AVB)


Rhythm IdentificationRhythm IdentificationThis rhythm strip is from an 81This rhythm strip is from an 81--yearyear--old female complaining of chest pain.old female complaining of chest pain.

141141



PR interval None


Identification ?


This rhythm strip is from an 81This rhythm strip is from an 81--yearyear--old female complaining of chest pain.old female complaining of chest pain.

142142



PR interval None




Rhythm IdentificationRhythm IdentificationThis rhythm strip is from a 74This rhythm strip is from a 74--yearyear--old female complaining of weakness.old female complaining of weakness.

143143




Identification ?


This rhythm strip is from a 74This rhythm strip is from a 74--yearyear--old female complaining of weakness.old female complaining of weakness.

144144




Identification Ventricular demand pacemaker




145145

Ventricular rate/rhythm 40 bpm (sinus beats)/Regular except for the event (every other beat is an ectopic beat)

Atrial rate/rhythm 40 bpm (sinus beats)/Regular except for the event


QRS duration ?

Identification ?



146146

Ventricular rate/rhythm 40 bpm (sinus beats)/Regular except for the event (every other beat is an ectopic beat)

Atrial rate/rhythm 40bpm (sinus beats)/Regular except for the event



Identification Sinus bradycardia with ventricular bigeminy




147147

Ventricular rate/rhythm 47 bpm using calculation by division/regular


PR interval None

QRS duration ?

Identification ?



148148

Ventricular rate/rhythm 47 bpm using calculation by division/regular


PR interval None




Rhythm IdentificationRhythm IdentificationThese rhythm strips are from a 63These rhythm strips are from a 63--yearyear--old female who experienced a syncopal old female who experienced a syncopal episode. Blood pressure is 200/90, blood sugar is 98.episode. Blood pressure is 200/90, blood sugar is 98.

149149




QRS duration ?

Identification ?


These rhythm strips are from a 63These rhythm strips are from a 63--yearyear--old old feamlefeamle who experienced a syncopal who experienced a syncopal episode. Blood pressure is 200/90, blood sugar is 98.episode. Blood pressure is 200/90, blood sugar is 98.

150150





Identification 2nd Degree AVB, 2:1 AV block


This rhythm strip is from an 84This rhythm strip is from an 84--yearyear--old female with a nosebleed. Blood old female with a nosebleed. Blood

pressure: 250/74. pressure: 250/74.


151151



PR interval ?


Identification ?


This rhythm strip is from an 84This rhythm strip is from an 84--yearyear--old female with a nosebleed. Blood old female with a nosebleed. Blood

pressure: 250/74. pressure: 250/74.

152152





Identification Sinus rhythm or NSR


Rhythm IdentificationRhythm IdentificationThis rhythm strip is from a 79This rhythm strip is from a 79--yearyear--old man complaining of palpitations. His old man complaining of palpitations. His initial blood pressure was 112/84. His second blood pressure, 8 minutes initial blood pressure was 112/84. His second blood pressure, 8 minutes after the first, was 78/Pafter the first, was 78/P

153153





Identification ?


This rhythm strip is from a 79This rhythm strip is from a 79--yearyear--old man complaining of palpitations. His old man complaining of palpitations. His initial blood pressure was 112/84. His second blood pressure, 8 minutes initial blood pressure was 112/84. His second blood pressure, 8 minutes after the first, was 78/Pafter the first, was 78/P

154154





Identification Narrow-QRS tachycardia (SVT)



155155


Ventricular paced activity? ?


Identification ?


156156






Rhythm IdentificationRhythm IdentificationThis rhythm strip is from an 80This rhythm strip is from an 80--yearyear--old man complaining of weakness and old man complaining of weakness and dizziness. Blood pressure is 160/98, blood sugar is 88.dizziness. Blood pressure is 160/98, blood sugar is 88.

157157





Identification ?


This rhythm strip is from an 80This rhythm strip is from an 80--yearyear--old man complaining of weakness and old man complaining of weakness and dizziness. Blood pressure is 160/98, blood sugar is 88.dizziness. Blood pressure is 160/98, blood sugar is 88.

158158








159159

Ventricular rate/rhythm 60 bpm/irregular (using rule of 10)




Identification ?


160160





Identification Second-degree AV block, type II


Rhythm IdentificationRhythm IdentificationThis rhythm strip is from a 58This rhythm strip is from a 58--yearyear--old man with chest pain that he rates as a 2 old man with chest pain that he rates as a 2 on a scale of 0 to 10. He states he recently began taking pills for weight control.on a scale of 0 to 10. He states he recently began taking pills for weight control.

161161

Ventricular rate/rhythm 90 bpm (sinus beats)/Regular except for the 3 event(s)




Identification ?


This rhythm strip is from a 58This rhythm strip is from a 58--yearyear--old man with chest pain that he rates as a 2 old man with chest pain that he rates as a 2 on a scale of 0 to 10. He states he recently began taking pills for weight control.on a scale of 0 to 10. He states he recently began taking pills for weight control.

162162

Ventricular rate/rhythm 90 bpm (sinus beats)/Regular except for the 3 event(s)

Atrial rate/rhythm 90 bpm (sinus beats)/Regular except for the event(s)



Identification Sinus rhythm with unifocal PVCs


Rhythm IdentificationRhythm IdentificationThis rhythm strip is from a 60This rhythm strip is from a 60--yearyear--old female complaining of palpitations and old female complaining of palpitations and shortness of breath.shortness of breath.

163163

Ventricular rate/rhythm 180 using rule of 10



QRS duration ?

Identification ?


This rhythm strip is from a 60This rhythm strip is from a 60--yearyear--old female complaining of palpitations and old female complaining of palpitations and shortness of breath.shortness of breath.

164164

Ventricular rate/rhythm 180 using rule of 10



QRS duration 0.08 sec (most)

Identification Atrial fibrillation with a rapid ventricular response (RVR)


Rhythm IdentificationRhythm IdentificationThis rhythm strip is from a 60This rhythm strip is from a 60--yearyear--old female complaining of palpitations, had SVT old female complaining of palpitations, had SVT on the monitor after administration of adenosine 6 mg IV for the SVT. Vagal on the monitor after administration of adenosine 6 mg IV for the SVT. Vagal maneuvers did not work.maneuvers did not work.

165165

Ventricular rate/rhythm 40-50 bpm/irregular; using rule of 10



QRS duration ?

Identification ?


This rhythm strip is from a 60This rhythm strip is from a 60--yearyear--old female complaining of palpitations, had old female complaining of palpitations, had SVT on the monitor after administration of adenosine 6 mg IV for the SVT. Vagal SVT on the monitor after administration of adenosine 6 mg IV for the SVT. Vagal maneuvers did not work.maneuvers did not work.

166166

Ventricular rate/rhythm 40-50 bpm/irregular: using rule of 10






Rhythm IdentificationRhythm IdentificationThis rhythm strip is from a 60This rhythm strip is from a 60--yearyear--old female complaining of persistent old female complaining of persistent palpitations and shortness of breath 1 minute after administration of adenosine palpitations and shortness of breath 1 minute after administration of adenosine 12 mg IV.12 mg IV.

167167

Ventricular rate/rhythm 30 bpm/irregular; using rule of 10




Identification ?


This rhythm strip is from a 60This rhythm strip is from a 60--yearyear--old female complaining of persistent old female complaining of persistent palpitations and shortness of breath, 1 minute after administration of palpitations and shortness of breath, 1 minute after administration of adenosine 12 mg IV.adenosine 12 mg IV.

168168

Ventricular rate/rhythm 30 bpm/irregular; using rule of 10






Rhythm IdentificationRhythm IdentificationThis rhythm strip is from a 60This rhythm strip is from a 60--yearyear--old female complaining of palpitations and old female complaining of palpitations and shortness of breath two minutes after administration of adenosine 6 mg IV.shortness of breath two minutes after administration of adenosine 6 mg IV.

169169





Identification ?


This rhythm strip is from a 60This rhythm strip is from a 60--yearyear--old female complaining of palpitations and old female complaining of palpitations and shortness of breath two minutes after administration of adenosine 6 mg IV.shortness of breath two minutes after administration of adenosine 6 mg IV.

170170





Identification Atrial fibrillation, rapid ventricular response (RVR)


Identify the missing m

Documents

Arrhythmia Case Studies Module - Baptist Health South Floridacontent.baptisthealth.net/healthstream/Arrhythmia_Case_Studies_with_Rhythm_Assessment...To analyze an ECG tracing, approach