Email : kimberly@avancelearning.com
Contact : 813-508-1511
Aehlert, B. (2002) ACLS Quick Review Study Guide. St Louis, MO: Mosby, Inc.
Allen, D., Bekken, & N., Crisfulla, K., et al. (2011) ECG Interpretation Made Incredibly Easy (5th ed.). Philadelphia, PA: Wolters Kulwer/Lippincott Williams & Wilkins.
Brose, J. A., Auseon, J. C., Waksman, D., & Jarosick, M. J. (2000) The Guide to EKG Interpretation, Revised Edition. Athens, OH: Ohio University Press.
Cason, L., Grbach, W., & Groban, M., et al. (2013) ACLS Review Made Incredibly Easy (2nd ed.). Philadelphia, PA: Wolters Kulwer/Lippincott Williams & Wilkins.
Ellis, K. M. (2002) EKG in a Heartbeat. Upper Saddle River, NJ: Prentice Hall.
Hazinski, M. F., Cummins, R. O., & Field, J. M. (Eds.) (2002) Handbook of Emergency Cardiovascular Care for Healthcare Providers. Dallas, TX: American Heart Association.
Hodges, R. K., Garrett, K. M., Chernecky, C., & Schumacher, L. (2005) Real-World Nursing Survival Guide: Hemodynamic Monitoring. St Louis, MO: Elsevier Saunders.
Huff, J. (2012) ECG Workout: Exercises in Arrhythmia Interpretation (6th ed.). Philadelphia, PA: Wolters Kulwer/Lippincott Williams & Wilkins.
Schumacher, L. & Chernecky, C. (2005) Real-World Nursing Survival Guide: Critical Care and Emergency Nursing. St Louis, MO: Elsevier Saunders.
Texas Heart Institute
http://www.texasheartinstitute.org
American College of Surgeons Online
http://www.acssurgery.com
American Association of Critical Care Nurses
http://www.aacn.org
4- Excellent, 3- Good, 2- Fair, 1- Poor
4- Excellent, 3- Good, 2- Fair, 1- Poor
How does the course work? Check out our intro video here:
Regularity: R-R equal, regular
Rate: 83
P waves: Upright, uniform, one before every QRS
PRI: 0.16
QRS: 0.08
Regularity: R-R equal at beginning of strip and narrows at end of strip but still equal to each other at end, regular
Rate: 90- speeding up to 100 at end of strip
P waves: Upright, uniform, one before every QRS
PRI: 0.12
QRS: 0.08
Regularity: R-R equal, regular
Rate: 81
P waves: Upright, uniform, one before every QRS
PRI: 0.14
QRS: 0.06
Regularity: R-R equal, regular
Rate: 62
P waves: Upright, uniform, one before every QRS
PRI: 0.16
QRS: 0.06
Regularity: R-R equal, regular
Rate: 142
P waves: Upright, uniform, one before every QRS
PRI: 0.16
QRS: 0.06
Regularity: R-R equal, regular
Rate: 43
P waves: Upright, uniform, one before every QRS
PRI: 0.20
QRS: 0.10
Regularity: R-R equal, regular
Rate: 75
P waves: Upright, uniform, one before every QRS
PRI: 0.18
QRS: 0.08
Regularity: R-R not equal, irregularly irregular
Rate: 90
P waves: fibrillating, indiscernible
PRI: N/A
QRS: 0.06
Regularity: R-R equal except for one early beat, slightly irregular
Rate: 70
P waves: Upright, uniform, one before every QRS except for premature beat
PRI: 0.18 except premature beat
QRS: 0.10
Premature beat: p wave not seen because it is hidden in T wave of previous complex. QRS is 0.08.
Regularity: R-R not equal, irregularly irregular
Rate: 40
P waves: Upright, not uniform, one before every QRS
PRI: varies with each complex
QRS: 0.08
Regularity: R-R equal, regular
Rate: 75
P waves: Upright, sawtooth, more P waves than QRS
PRI: not measured
QRS: 0.08
Regularity: R-R equal, regular
Rate: 94
P waves: inverted, uniform, one before every QRS
PRI: 0.16
QRS: 0.08
Regularity: R-R equal, regular
Rate: 51
P waves: Not seen, possibly inverted after QRS
PRI: N/A
QRS: 0.12
Regularity: R-R equal except for two early beats, slightly irregular
Rate: 70
P waves: Upright, uniform, one before every QRS, except premature beats
PRI: 0.16 except premature beats
QRS: 0.06
Premature beats: both have missing P waves, QRS is 0.06
Regularity: R-R equal, regular
Rate: 107
P waves: inverted, uniform, one before every QRS
PRI: 0.16
QRS: 0.08
Premature beats: both have missing P waves, but QRS is 0.06
Regularity: R-R equal, regular
Rate: 47
P waves: not seen
PRI: not measured
QRS: 0.08
Regularity: R-R equal, regular
Rate: 35
P waves: upright, uniform, but not all followed by QRS
PRI: 0.16 on conducted beats- only every third beat
QRS: 0.06
Regularity: R-R slightly irregular
Rate: 90
P waves: upright, uniform, but not all followed by QRS
PRI: progressively widening until one P wave have no QRS, then cycle restarts
QRS: 0.06
Regularity: R-R, regular
Rate: 54
P waves: upright, uniform, all followed by QRS
PRI: 0.24
QRS: 0.10
Regularity: R-R, regular
Rate: 75
P waves: upright, uniform, but not all followed by QRS
PRI: immeasurable as there is no relationship with QRS complexes
QRS: 0.08
Regularity: R-R, regular
Rate: 25
P waves: none
PRI: N/A
QRS: 0.16
Regularity: R-R regularly irregular
Rate: 80
P waves: upright, uniform, but not one before every QRS
PRI: 0.18
QRS: 0.08 except for premature beats
Premature beats: No P wave before then, wide QRS, occur every other beat
Regularity: R-R irregularly irregular
Rate: 180
P waves: fibrillating, indiscernible
PRI: N/A
QRS: 0.08 except for premature beat
Premature beat: No P wave before it, wide QRS, is a single beat
Regularity: R-R slightly irregular
Rate: 100
P waves: upright, uniform, but not one before every QRS
PRI: 0.14
QRS: 0.04 except premature beats
Premature beats: No P waves before them, similar in appearance, no pattern of occurrence
Regularity: R-R regular
Rate: 150
P waves: none seen
PRI: N/A
QRS: 0.34
Regularity: R-R regular
Rate: 58
P waves: none seen
PRI: N/A
QRS: 0.12
Regularity: R-R not measurable
Rate: not measurable
P waves: none
PRI: N/A
QRS: not measurable
Regularity: R-R irregularly irregular
Rate: 90
P waves: fibrillating, not measurable
PRI: N/A
QRS: 0.10
Regularity: R-R regular
Rate: 56
P waves: upright, uniform, one before every QRS
PRI: 0.24
QRS: 0.16
Regularity: R-R regularly irregular
Rate: 100
P waves: upright, uniform, except for premature beats
PRI: 0.14
QRS: 0.06
Premature beats: No P waves seen, QRS 0.08
Regularity: R-R regular
Rate: 95
P waves: pacer spike before each
PRI: N/A because there is a pacer spike before QRS also
QRS: 0.12 with pacer spike before each
Regularity: R-R regular
Rate: 115
P waves: upright, uniform, one before every QRS
PRI: 0.16
QRS: 0.08
Regularity: R-R regular
Rate: 52
P waves: upright, uniform, one before every QRS
PRI: 0.14
QRS: 0.08
Regularity: R-R regular
Rate: 205
P waves: not seen, may be hidden in T wave
PRI: N/A
QRS: 0.08
Regularity: R-R regularly irregular
Rate: 80
P waves: upright, uniform, not one before every QRS
PRI: 0.18 except premature beats
QRS: 0.10 except premature beats
Premature beats: no P wave before them, occurs every other beat, similar in appearance, QRS 0.16
Regularity: R-R regular
Rate: 38
P waves: none
PRI: N/A
QRS: 0.18
Regularity: R-R regular
Rate: 75
P waves: none seen
PRI: N/A
QRS: 0.08
Regularity: R-R regular
Rate: 175
P waves: none
PRI: N/A
QRS: 0.20
Regularity: R-R slightly irregular
Rate: 70
P waves: upright, uniform, not all followed by QRS
PRI: progressively widening until one P wave have no QRS, then cycle restarts
QRS: 0.10
Regularity: R-R slightly irregular
Rate: 80
P waves: upright, but not uniform- appearance differs toward end of strip, one before every QRS
PRI: varies
QRS: 0.04
Regularity: R-R regular
Rate: 52
P waves: upright, uniform, one before every QRS
PRI: 0.20
QRS: 0.08
Regularity: R-R slightly irregular
Rate: 90
P waves: upright, uniform, one before every QRS except premature beats
PRI: 0.16 except premature beats
QRS: 0.10 except premature beats
Premature beats: No p waves before QRS, 3 in a row, similar in appearance, QRS 0.12
Regularity: R-R regular
Rate: 83
P waves: sawtooth
PRI: not measured
QRS: 0.06
Regularity: R-R regular
Rate: 37
P waves: upright, uniform, not every one is followed by QRS
PRI: 0.32 on conducted beats
QRS: 0.12
Regularity: R-R regular
Rate: 63
P waves: upright, uniform, and one before every QRS
PRI: 0.36
QRS: 0.16
Regularity: R-R regular
Rate: 45
P waves: upright, uniform, no relationship with QRS
PRI: immeasurable
QRS: 0.08
Regularity: R-R regular
Rate: 60
P waves: none
PRI: N/A
QRS: 0.06
Regularity: R-R regular
Rate: 190
P waves: not seen
PRI: N/A
QRS: 0.08
Regularity: R-R slightly irregular
Rate: 70
P waves: upright, uniform, but not all followed by QRS
PRI: progressively widening until one P wave have no QRS, then cycle restarts
QRS: 0.08
Regularity: R-R regular
Rate: 79
P waves: upright, uniform, one before every QRS
PRI: 0.16
QRS: 0.08
Regularity: R-R regular
Rate: 34
P waves: none
PRI: N/A
QRS: 0.12
Regularity: Immeasurable
Rate: Immeasurable
P waves: none seen
PRI: Immeasurable
QRS: Immeasurable
Regularity: R-R regular
Rate: 65
P waves: upright, uniform, but not all followed by QRS
PRI: 0.26 on conducted beats
QRS: 0.06
Regularity: R-R regular
Rate: 65
P waves: upright, uniform, but not one before every QRS
PRI: not measured
QRS: pacer spike before every one
Regularity: R-R slightly irregular
Rate: 70
P waves: upright, uniform, one before every QRS, except premature beat
PRI: 0.16 except premature beat
QRS: 0.08 except premature beat
Premature beat: no P wave before it, only one, QRS 0.16
Regularity: R-R regular
Rate: 140
P waves: none
PRI: N/A
QRS: 0.36
Regularity: R-R regular
Rate: 110
P waves: upright, uniform, one before every QRS
PRI: 0.16
QRS: 0.08
Regularity: R-R regular
Rate: 50
P waves: upright, uniform, one before every QRS
PRI: 0.12
QRS: 0.04
Regularity: R-R regularly irregular
Rate: 45
P waves: upright, uniform, no relationship with QRS
PRI: N/A
QRS: 0.10
Regularity: R-R regular at the beginning of strip then irregular toward the end
Rate: 140
P waves: not measurable
PRI: N/A
QRS: 0.08
Regularity: R-R slightly irregular- one early beat
Rate: 70
P waves: upright, uniform, one before every QRS
PRI: 0.16
QRS: 0.08
Premature beat: Upright P wave before QRS, only one occurance, QRS 0.08
Regularity: R-R regular
Rate: 75
P waves: not seen
PRI: N/A
QRS: 0.08
Regularity: R-R regular
Rate: 35
P waves: upright, uniform, no relationship with QRS
PRI: N/A
QRS: 0.20
Regularity: R-R regular
Rate: 68
P waves: upright, uniform, one before every QRS
PRI: 0.14
QRS: 0.08
Regularity: R-R regular
Rate: 75
P waves: sawtooth
PRI: not measured
QRS: 0.08
Regularity: R-R slightly irregular, one early beat
Rate: 65
P waves: upright, uniform, one before every QRS, except P wave appearance different in premature beat
PRI: 0.18
QRS: 0.08
Premature beat: Upright P wave before QRS, one occurrence, QRS 0.08
Regularity: R-R slightly irregular- one early beat
Rate: 60
P waves: upright, uniform, one before every QRS except for premature beat
PRI: 0.16
QRS: 0.04
Premature beat: No P wave before QRS seen, one occurrence, QRS 0.04
Regularity: R-R regular
Rate: 105
P waves: upright, uniform, one before every QRS
PRI: 0.12
QRS: 0.08
Regularity: R-R slightly irregular, a few early beats
Rate: 80
P waves: sawtooth
PRI: not measured
QRS: 0.08
TIME FOR PRACTICE RHYTHM STRIPS ON ALL RHYTHMS
(Please refer to "Answers to Practice Rhythm Strips" category for answer key)
Pacemakers can be temporary or permanent. Temporary are used in emergencies and usually used only a few days at most. They inserted transvenously (inserted through a vein) or applied transcutaneously (on the skin).
Transvenous Pacemaker
Transvenous Pacemaker
Transcutaneous Pacing
Permanent Pacemaker (Dual Chamber)
What does a pacemaker do to an EKG rhythm strip?
... it creates pacer spikes.
a. Types of Pacing Response
Example EKG strip with Triggered pacing
1) Triggered- Fixed rate. Fires according to a predetermined program regardless of patient’s underlying heart rate or rhythm. (i.e. pacer is programmed to send 75 impulses to the ventricles every minute regardless of what the atria are doing as in the strip below).
Example EKG strip with Inhibited pacing
2) Inhibited- Fires only when needed. Senses patient’s own rhythm and inhibits its impulse until needed (i.e. the ventricle or atria stop beating or are beating too slow, etc). In the strip below, you can see the pacer only kicks in after the patient's ventricles fail to beat.
Can be both: Triggered atrial, (this means the pacer sends an impulse to the atria regardless of how the atria are beating) and inhibited ventricular (this means it senses ventricular beats and fires only when ventricles need it to).
b. Common Kinds of Inhibited Pacers
1) Single chamber- Senses and stimulates either atria or ventricles but not both
2) Dual chamber-Works on both chambers simultaneously. Most common is DDD-Dual pacing for both chambers, Dual chamber activity sensing, and Dual response (triggering and inhibition).
c. Assessment
Always check your patient to assure the mechanical and electrical are both working.
1) Things to assess
· Does each pacer spike capture and get followed by either a P wave or QRS (depending on the type of pacer)?
(In the picture below, there are way more pacer spikes than QRS's, not every pacer spike is followed by a QRS meaning that even though the pacer is firing as programmed, the heart is not responding appropriately.)
· Is the rate reasonable? (Usually 60-100)
· Are the pacer spikes competing with the patient’s underlying rhythm or falling near T waves? (Spikes falling near T waves can throw a patient into Vtach or Torsades)
· Is pacer firing consistently and reliably?
d. Common Malfunctions
1) Failure to Capture- pacer firing, creating pacer spikes, but heart does not respond (no P wave or QRS after)
2) Failure to Pace- Pacer fails to deliver correct number of stimuli or sometimes any stimulus at all.
3) Competing with patient’s own intrinsic rhythm- can be for two reason and either of these can be bad if the depolarized beat falls near the T wave of the previous beat