Professional Documents
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Rhythms
Identification
and Response
Module 1
ANATOMY, PHYSIOLOGY, &
ELECTRICAL CONDUCTION
Objectives
Describe the normal cardiac anatomy and physiology and normal
electrical conduction through the heart.
Identify and relate waveforms to the cardiac cycle.
Cardiac Anatomy
2 upper chambers
Right and left atria
2 lower chambers
Right and left ventricle
Systemic Circulation
Oxygenated left side of the heart
Anatomy
Coronary Arteries
Anatomy
Coronary Arteries
2 major vessels of the coronary circulation
Left main coronary artery
Left anterior descending and circumflex branches
The left and right coronary arteries originate at the base of the
aorta from openings called the coronary ostia behind the aortic
valve leaflets.
Physiology
Blood Flow
Unoxygenated blood flows from
inferior and superior vena cava
Right Atrium
Tricuspid Valve
Right Ventricle
Pulmonic Valve
Lungs
Through Pulmonary system
Physiology
Blood Flow
Oxygenated blood flows from the
pulmonary veins
Left Atrium
Mitral Valve
Left Ventricle
Aortic Valve
Systemic Circulation
Blood Flow Through The Heart
Cardiology Rap
Physiology
Cardiac cycle
Represents the actual time sequence between ventricular contraction
and ventricular relaxation
Systole
Simultaneous contraction of the ventricles
Diastole
Synonymous with ventricular relaxation
When ventricles fill passively from the atria to 70% of blood capacity
Physiology
Heart rate (HR)
Number of contractions (beats per minute)
Normal heart rate is 60 100 beats per minute (bpm)
Physiology
Cardiac output (CO)
Amount of blood pumped by the left ventricle in one minute
Normal cardiac output is 4 8 L/min
Cardiac Output =
Physiology
Pre-load
Volume and stretch of the ventricular myocardium at the end of
diastole
After-load
Amount of pressure against which the left ventricle must work during
systole to open the aortic valve
Clinically measure by systolic blood pressure
Inter-nodal pathways
AV node
Bundle of his
Left & Right bundle branches
Purkinje fibers
P, Q, R, S, (QRS complex),
and T wave
QRS Complex
Ventricular depolarization, atrial repolarization
T wave
Ventricular repolarization (resting phase)
Module 2
INTERPRETING EKG
RHYTHM STRIPS
Objectives
Utilize a systematic process when approaching the interpretation
of the EKG.
Identify normal and abnormal components on the EKG.
EASI Lead
Lead Placement
Color Code
Amplitude (voltage)
Measured on the vertical line
Read every strip from left to right, starting at the beginning of the
strip
Apply the five-step systematic approach that you will learn in this
module for consistency with each strip that you interpret
4. PR interval
5. QRS complex
1. Find an R to R
Measuring PR Interval:
R wave
First upward or positive deflection following the
P wave (tallest waveform)
S wave
The sharp, negative or downward deflection
that follows the R wave
2. Are the QRS complexes less than 0.06 seconds (in width)?
3. Are the QRS complexes similar in appearance across the EKG strip?
Module 3
SINUS RHYTHMS
Objectives
Recognize sinus dysrhythmias on EKG and relate cause,
significance, symptoms, and treatment.
Sinus Rhythms
Rhythms that originate in the sinoatrial node (SA node)
5 Common Variations of a sinus rhythm:
Yes
Yes
4. What is the length of the PR interval?
Yes
0.06-0.12 seconds (1 to 3 small squares)
Sinus Bradycardia
Sinus bradycardia is a regular but unusually slow heart beat (less than
60 bpm). Sinus bradycardia is often seen as a normal variation in
athletes, during sleep, or in response to a vagal maneuver.
Yes
Yes
Yes
Hypoglycemia
Syncope
Hypothermia
Dizziness
Hypothyroidism
Chest Pain
Shortness of Breath
Medications
Exercise Intolerance
Toxic exposure
Medical Treatment
Atropine
Pacing if the patient is
hemodynamically compromised
Treatment will be based on whether
patient is symptomatic
Notify MD
Sinus Tachycardia
Sinus Tachycardia is a fast heartbeat related to a rapid firing of the
sinoatrial (SA) node. The clinical dysrhythmia depends on the underlying
cause. It may be normal depending on the patient.
Yes
Yes
Yes
0.06-0.12 seconds (1 to 3 small squares)
Dizziness
Hypertension
Shortness of breath
Fever
Lightheadedness
Stress
Heart palpitations
Chest pain
Syncope
Medical Treatment
Narrow QRS Complexes consider vagal maneuvers, adenosine, beta blocker, calcium channel blocker,
or synchronized cardioversion
Wide QRS Complexes consider anti-arrhythmic such as procainamide, amiodarone, or sotalol
Sinus Arrhythmia
Sinus arrhythmia is a normal variation in the beating of your heart. A sinus
arrhythmia refers to an irregular or disorganized heart rhythm.
This rate usually increases with inspiration and decreases with expiration.
Yes
Yes
Yes
0.06-0.12 seconds (1 to 3 small
squares)
Heart disease
Usually asymptomatic
Medical Treatment
Sometimes asymptomatic
Myocarditis
Cardiomyopathy
MI
Digitalis toxicity
Age- elderly
Vagal stimulation
Syncope
Dizziness
LOC
Bradycardia
Medical Treatment
Syncope
Fall
Thromboembolic events including stroke
CHF
Atrial tachyarrhythmias - such as atrial
flutter or fibrillation
Atropine
Pacemaker
Electrolyte imbalance
Natural deterioration of the cardiac system
Lets Practice!!
References
E-Medicine Health (2012). Retrieved from
http://www.emedicinehealth.com/script/main/hp.asp
Heart Start Skills (2009). Retrieved from
http://www.youtube.com/watch?v=1nhThfSWU7U&feature=autoplay&list=UUDG
8UqA26LciIovorpr_bJQ&playnext=3
MedicineNet.com (2012). Cardiac arrhythmias. Retrieved from
http://www.medicinenet.com
Medscape (2012). Retrieved from http://www.medscape.com
Module 4
ATRIAL RHYTHMS
Learning Outcomes
Atrial Rhythms
When the sinoatrial (SA) node fails to generate an impulse; atrial
tissues or internodal pathways may initiate an impulse
The 4 most common atrial arrhythmias include:
Atrial Flutter
Atrial flutter is a coordinated rapid beating of the atria. Atrial flutter is the
second most common tachyarrhymia.
Atrial: regular
Ventricular: may be irregular
Not measurable
Yes
Palpitations
SOB
Anxiety
Ischemia
Weakness
Cardiomyopathy
Angina
COPD
Syncope
Emphysema
Medical Treatment
Stroke
Pulmonary Embolism
Atrial Fibrillation
The electrical signal that circles uncoordinated through the muscles of the atria
causing them to quiver (sometimes more than 400 times per minute) without
contracting. The ventricles do not receive regular impulses and contract out of
rhythm, and the heartbeat becomes uncontrolled and irregular. It is the most
common arrhythmia, and 85 percent of people who experience it are older than
65 years.
No distinguishable P waves
Irregularly irregular
Not discernable
Yes
Hypoxia
Heart palpitations
Hypertension
Dizziness or light-headedness
Fainting
Confusion
Fatigue
Trouble breathing
Medical Treatment
Rate control
Stroke
Pulmonary Embolism
Antithrombotic therapy
Correction of rhythm
Chemical or electrical cardioversion
http://www.youtube.com/watch?v=d0YjiPTd55k&feature=channel&list=UL
Regular
Yes
Palpitations
Stimulants
Hypoxia
Lightheadedness or dizziness
Stress or over-exertion
Syncope
Hypokalemia
Shortness of breath
A pounding pulse.
Sweating
Tightness or fullness in the throat
Tiredness (fatigue)
Medical Treatment
Drug management
Adenosine
Cardioversion if unstable
Yes
Palpitations
Stress
Stimulants
Hypertension
Valvular condition
Infectious diseases
Hypoxia
Skipped beat
Medical Treatment
No treatment necessary if
asymptomatic
Lets Practice!!
References
E-Medicine Health (2012). Retrieved from
http://www.emedicinehealth.com/script/main/hp.asp
Heart Start Skills (2009). Retrieved from
http://www.youtube.com/watch?v=1nhThfSWU7U&feature=autoplay&list=UUDG8
UqA26LciIovorpr_bJQ&playnext=3
Module 5
VENTRICULAR RHYTHMS
Objectives
Recognize ventricular dysrhythmias on EKG and relate cause,
significance, symptoms, and treatment.
Ventricular Rhythms
When the sinoatrial (SA) node and the AV Junctional tissues fails to generate an
impulse the ventricles will assume the role of pacing the heart
Ventricular rhythms will display QRS complexes that are wide (greater than or
equal to 0.12 seconds) and bizarre in appearance
Ventricular Rhythms
The most common variations:
Premature ventricular contractions (PVCs)
These 8 rhythms are the lethal ones: KNOW THESE
Idioventricular rhythm (ventricular escape rhythm; rate usually >20 <40 bpm)
Accelerated Idioventricular rhythm (>40 bpm)
Agonal rhythm (20 or less bpm)
Ventricular tachycardia (>150 bpm)
Ventricular fibrillation
Torsades de Pointes
Pulseless Electrical Activity (PEA)
Asystole - Cardiac Standstill
Varies
Wide and bizarre (>0.12 sec), occurs earlier than expected
PVC Patterns
Ventricular bigeminy
Ventricular trigeminy
Ventricular quadrigeminy
Couplets
Exercise
Palpitations
Stress
Weakness
Caffeine
Dizziness
Hypotension
Electrolyte imbalances
Hypoxia
Tricyclic antidepressants
Digitalis toxicity
Treatment
Oxygen
Heart failure
Idioventricular Rhythm
Idioventricular arrhythmia is also termed ventricular escape rhythm. It is
considered a last-ditch effort of the ventricles to try to prevent cardiac standstill.
The SA node and AV node have failed
Rate usually between 20 to 40 beats per minute (bpm)
Cardiac output is compromised!!
Usually regular
Absent
Not measureable
Drugs- Digitalis
Pale
MI
Metabolic imbalances
Weakness
Hyperkalemia
Dizziness
Cardiomyopathy
Hypotension
Alteration in mental status
Risk
Medical Treatment
Atropine
Pacing
CPR
Notify MD
Start IV if not already established and hang NS
Usually regular
Absent
Not measureable
Causes
Drugs- Digitalis
Pale
MI
Metabolic imbalances
Weakness
Hyperkalemia
Dizziness
Cardiomyopathy
Hypotension
Alterations in mental status
Medical Treatment
Atropine
Pacing
CPR
Notify MD
Start IV if not already established and hang NS
Agonal Rhythm
Agonal rhythm is when the Idioventricular rhythm is 20 beats or less
per minute. Frequently is seen as the last-ordered semblance of a
heart rhythm when resuscitation efforts are unsuccessful.
Usually regular
Absent
Not measureable
Trauma
Loss of consciousness
Acute MI
Medical Treatment
Death
CPR/ACLS Protocol
If life saving efforts have already
been attempted no further
treatment
Ventricular Tachycardia
Ventricular tachycardia almost always occurs in diseased hearts.
Rhythm in which three or more PVCs arise in sequence at a rate greater than 100 beats per
minute.
V-tach can occur in short bursts lasting less than 30 seconds, causing few or no symptoms.
Sustained v-tach lasts for more than 30 seconds and requires immediate treatment to prevent
death.
V-tach can quickly deteriorate into ventricular fibrillation.
101-250 bpm
No
Not measureable
Light-headedness or dizziness
Syncope
Palpitations
Electrolyte imbalance
Digitalis toxicity
Loss of consciousness
Hypotension
Shortness of breath
Medical Treatment
Ventricular Fibrillation
V-Fib (coarse and fine)
Occurs as a result of multiple weak ectopic foci in the ventricles
No coordinated atrial or ventricular contraction
Electrical impulses initiated by multiple ventricular sites; impulses are not transmitted through
normal conduction pathway
Not discernible
No
None
None
AMI
Loss of consciousness
Untreated VT
Absent pulse
Electrolyte imbalance
Hypothermia
Myocardial ischemia
Drug toxicity or overdose
Trauma
Medical treatment
Death
Regular or irregular
No
Not measurable
Chest pain
Dizziness
Phenothiazine or tricyclic
antidepressant overdose
Electrolyte disturbances,
especially hypokalemia and
hypomagnesemia
Loss of consciousness
Nausea
Shortness of breath
Death
Medical Treatment
Asystole
Ventricular standstill
none
none
none
none
none
No palpable pulse
Loss of consciousness
Cardiac tamponade
Prolonged v-fib
Pulmonary embolism
No measurable BP
Medical Treatment
CPR
ACLS protocol
Hypovolemia #1 cause
Hypoxia
Hydrogen ions (acidosis)
Hypo / Hyperkalemia
Hypothermia
Toxins
Tamponade (cardiac)
Tension pneumothorax
Thrombosis (coronary or pulmonary)
Trauma
Massive MI
Overdose of tricyclic antidepressants
Pulselessness
Loss of consciousness
No palpable BP
Medical Treatment
Lets Practice!!
All types of strips
References
Aehlert, B. (2006). ECGs made easy (3rd ed.). Missouri: MosbyJems Elsevier.
American Heart Association. (2011). Advanced cardiovascular life support provider manual. Dallas: American
Heart Association.
ACLS Algorithms. (2012). Learn and master. Retrieved from http://acls-algorithms.com/
E-Medicine Health. (2012). Retrieved from http://www.emedicinehealth.com/script/main/hp.asp
Heart Start Skills. (2009). Retrieved from
http://www.youtube.com/watch?v=1nhThfSWU7U&feature=autoplay&list=UUDG8UqA26LciIovorpr_bJQ&play
next=3
MedicineNet.com. (2012). Cardiac arrhythmias. Retrieved from http://www.medicinenet.com
Medscape. (2012). Retrieved from http://www.medscape.com
Nagell, K. & Nagell, R. (2003). A case-based approach to ECG interpretation. Missouri: MosbyJems.
Rhythm Identification
This rhythm strip is from an 86-year-old woman who experienced a
cardiopulmonary arrest. The initial rhythm was asystole. The
following rhythm resulted after IV administration of epinephrine
and atropine.
Copyright 2006
by Mosby Inc. All
rights reserved.
Ventricular rate/rhythm
40 bpm/regular
Atrial rate/rhythm
None
PR interval
None
QRS duration
0.18 sec
Identification
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Rhythm Identification
This rhythm strip is from a 69-year-old man complaining of
shortness of breath. Lung sounds reveal bilateral rales. Blood
pressure: 160/58.
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Ventricular rate/rhythm
Atrial rate/rhythm
PR interval
QRS duration
Identification
Rhythm Identification
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Ventricular rate/rhythm
214 bpm/regular
Atrial rate/rhythm
Unable to determine
PR interval
Unable to determine
QRS duration
0.14 sec
Identification
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Rhythm Identification
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Ventricular rate/rhythm
Atrial rate/rhythm
Unable to determine
PR interval
Unable to determine
QRS duration
Identification
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Rhythm Identification
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Ventricular rate/rhythm
88 bpm/regular
Atrial rate/rhythm
Unable to determine
PR interval
Unable to determine
QRS duration
0.06 sec
Identification
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Rhythm Identification
This rhythm strip is from a 52-year-old man found unresponsive,
apneic, and pulseless.
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Ventricular rate/rhythm
88 bpm/regular
Atrial rate/rhythm
None
PR interval
None
QRS duration
Identification
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Rhythm Identification
These rhythm strips are from a 78-year-old man complaining of
shortness of breath. He has a history of COPD, coronary artery
disease, and hypertension.
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Ventricular rate/rhythm
55 to 94 bpm/irregular
Atrial rate/rhythm
Unable to determine
PR interval
Unable to determine
QRS duration
0.10 sec
Identification
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Rhythm Identification
This rhythm strip is from an 86-year-old woman complaining of
chest pain that she rates a 4 on a scale of 0 to 10. Blood pressure:
142/72.
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rights reserved.
Ventricular rate/rhythm
60 bpm/regular
Atrial rate/rhythm
60 bpm/regular
PR interval
0.20 sec
QRS duration
0.06 sec
Identification
Sinus rhythm
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Rhythm Identification
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Ventricular rate/rhythm
Atrial rate/rhythm
PR interval
0.16 sec
QRS duration
Identification
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Rhythm Identification
This rhythm strip is from an 83-year-old man complaining of chest
pain. He had a new pacemaker implanted 5 days ago. His blood
pressure is 148/60.
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rights reserved.
Ventricular rate/rhythm
79 bpm/regular
Atrial rate/rhythm
Unable to determine
PR interval
Unable to determine
QRS duration
0.08 sec
Identification
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Rhythm Identification
This rhythm strip is from a 52-year-old man with substernal chest
pain. He has a history of COPD and mitral valve regurgitation.
Blood pressure: 140/78.
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by Mosby Inc. All
rights reserved.
Ventricular rate/rhythm
75 bpm/regular
Atrial rate/rhythm
75 bpm/regular
PR interval
0.14 sec
QRS duration
Identification
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Rhythm Identification
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Ventricular rate/rhythm
54 bpm/regular
Atrial rate/rhythm
Unable to determine
PR interval
Unable to determine
QRS duration
0.08 sec
Identification
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Rhythm Identification
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Ventricular rate/rhythm
None
Atrial rate/rhythm
None
PR interval
None
QRS duration
None
Identification
Asystole
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Rhythm Identification
This rhythm strip is from a 1-month-old infant after a 3-minute
seizure.
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Ventricular rate/rhythm
130 bpm/regular
Atrial rate/rhythm
130 bpm/regular
PR interval
QRS duration
Identification
Sinus tachycardia
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Rhythm Identification
This rhythm strip is from a 77-year-old woman with a congested
cough.
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Ventricular rate/rhythm
Atrial rate/rhythm
Unable to determine
PR interval
Unable to determine
QRS duration
Identification
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Rhythm Identification
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Ventricular rate/rhythm
Atrial rate/rhythm
PR interval
QRS duration
Identification
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Rhythm Identification
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Ventricular rate/rhythm
Atrial rate/rhythm
PR interval
QRS duration
Identification
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Rhythm Identification
This rhythm strip is from a 54-year-old man who had a syncopal
episode.
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Ventricular rate/rhythm
58 bpm/regular
Atrial rate/rhythm
58 bpm/regular
PR interval
0.20 sec
QRS duration
0.08 sec
Identification
Sinus bradycardia
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Rhythm Identification
This rhythm strip is from a 43-year-old woman complaining of
palpitations.
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Ventricular rate/rhythm
214 bpm/regular
Atrial rate/rhythm
Unable to determine
PR interval
Unable to determine
QRS duration
0.08 sec
Identification
Supraventricular tachycardia
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Rhythm Identification
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Ventricular rate/rhythm
Unable to determine
Atrial rate/rhythm
Unable to determine
PR interval
Unable to determine
QRS duration
Unable to determine
Identification
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Rhythm Identification
This rhythm strip is from an 88-year-old woman complaining of hip
pain after a fall injury.
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rights reserved.
Ventricular rate/rhythm
68 to 125 bpm/irregular
Atrial rate/rhythm
Unable to determine
PR interval
Unable to determine
QRS duration
0.08 sec
Identification
Atrial fibrillation
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Rhythm Identification
This rhythm strip is from an 82-year-old woman with vomiting x 2
days.
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Ventricular rate/rhythm
115 bpm/regular
Atrial rate/rhythm
115 bpm/regular
PR interval
0.18 sec
QRS duration
0.06 sec
Identification
Sinus tachycardia
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Rhythm Identification
This rhythm strip is from a 62-year-old woman complaining of
chest pain. Her blood pressure is 146/104, respirations are 20.
Breath sounds are clear.
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Ventricular rate/rhythm
167 bpm/regular
Atrial rate/rhythm
Unable to determine
PR interval
Unable to determine
QRS duration
0.06 sec
Identification
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Rhythm Identification
This rhythm strip is from a 6-year-old boy immediately after a
seizure.
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rights reserved.
Ventricular rate/rhythm
68 to 88 bpm/irregular
Atrial rate/rhythm
68 to 88 bpm/irregular
PR interval
0.12 sec
QRS duration
0.08 sec
Identification
Sinus arrhythmia
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rights reserved.
Rhythm Identification
These rhythm strips are from a 44-year-old woman complaining of
chest pain.
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Ventricular rate/rhythm
176 bpm/regular
Atrial rate/rhythm
None
PR interval
None
QRS duration
Identification
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Rhythm Identification
This rhythm strip is from an 81-year-old woman complaining of
chest pain.
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by Mosby Inc. All
rights reserved.
Ventricular rate/rhythm
76 bpm/regular
Atrial rate/rhythm
None
PR interval
None
QRS duration
Identification
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Rhythm Identification
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Ventricular rate/rhythm
Atrial rate/rhythm
PR interval
QRS duration
Identification
Rhythm Identification
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Ventricular rate/rhythm
42 bpm/regular
Atrial rate/rhythm
None
PR interval
None
QRS duration
0.24 sec
Identification
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Rhythm Identification
This rhythm strip is from an 18-year-old man with a gunshot wound to his
chest.
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Ventricular rate/rhythm
Unable to determine
Atrial rate/rhythm
None
PR interval
None
QRS duration
None
Identification
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Rhythm Identification
Ventricular rate/rhythm
88/min/regular
Atrial rate/rhythm
Unable to determine
PR interval
Unable to determine
QRS duration
0.06 sec
Identification
Lets Dance!