COURSE DESCRIPTION. Rev 2.0 7/2013. Page 1 of 26

COURSE DESCRIPTION Ventricular dysrhythmias (arrhythmias) are unique and potentially dangerous cardiac rhythms. They are often associated with Code Blue calls, and life and death situations. The only two cardiac arrhythmias treated with a defibrillator are in this category. This course will review the unique morphologic features of ventricular dysrhythmias, identify a five-step process for dysrhythmia interpretation, identify the toeholds (hallmarks) of each of the ventricular dysrhythmias, and present ECG strips to review and identify cardiac dysrhythmias. Rev 2.0 7/2013 Page 1 of 26

COURSE TITLE: Ventricular Dysrhythmias Author: Thomas E. O'Brien, AS, CST, CCT, CRAT Central Florida Institute Palm Harbor, FL 34684 Number of Clock Hours Credit: 3.0 Course # 1220911 P.A.C.E. Approved: _ Yes X No OBJECTIVES Upon completion of this continuing education course, the professional should be able to: 1. State the origin of the electrical impulses in ventricular dysrhythmias. 2. Identify the unique morphologic features of ventricular complexes. 3. Explain the absence of a P wave in ventricular complexes and dysrhythmias. 4. State the normal value for the QRS complex. 5. List terms associated with premature ventricular complexes and dysrhythmias. 6. Identify ventricular complexes and each ventricular dysrhythmia. 7. Specify the rate for each of the ventricular dysrhythmias. 8. Identify each step in the five-step process for dysrhythmia interpretation. 9. Identify the toeholds (hallmarks) of each of the ventricular dysrhythmias described in this course. 10. Given rhythm strips, identify the different cardiac dysrhythmias reviewed in this course. Disclaimer The writers for NCCT continuing education courses attempt to provide factual information based on literature review and current professional practice. However, NCCT does not guarantee that the information contained in the continuing education courses is free from all errors and omissions. Page 2 of 26

INTRODUCTION Dysrhythmias (arrhythmias) are abnormal heart rhythms that cause the heart to pump blood less effectively. Dysrhythmias are divided into two main categories: supraventricular and ventricular. Supraventricular dysrhythmias occur in the heart s the atria, the two upper chambers. Ventricular dysrhythmias occur in the heart s two lower chambers, which are the ventricles. Dysrhythmias cause about 250,000 deaths per year. Symptoms of dysrhythmias include palpitations or thumping in the chest, feeling tired or light-headed, fainting, shortness of breath, and / or chest pain. Patients may also experience dizziness and have excessive sweating. Ventricular dysrhythmias present as unique and potentially dangerous cardiac dysrhythmias. Ventricular dysrhythmias are often associated with Code Blue calls (calls for healthcare providers specifically trained in resuscitation of individuals with no heartbeat), and life and death situations. The only two cardiac dysrhythmias treated with a defibrillator are in this category. The typical function of the heart s pacemakers is based upon the premise that the fastest electrical impulses in the heart control the heart rate. Following are the locations and rates of automaticity of the pacemakers in the heart. Pacemaker Site Inherent Rate (beats per minute or bpm) Sinoatrial (SA) Node 60-100 Atrioventricular (AV) (junctional tissue) Node 40-60 Purkinje Fibers (ventricles) 20-40 Based upon these numbers, the normal heart rate (bpm) is based upon the fastest impulse. The normal functioning electrical conduction system is regulated by electrical impulses coming from the SA node, hence sinus rhythms. Each of the pacemaker sites of the heart are able to work above or below the rates stated above. When either the electrical activity ceases coming from the SA or AV junction, or impulses coming from the ventricles exceed and override the SA or AV node, the rhythm is referred to as ventricular. THE FIVE-STEP PROCESS OF DYSRHYTHMIA ANALYSIS The process of dysrhythmia analysis should be consistent and follow the five steps described below. Remembering these steps, the normal measurements, and what makes dysrhythmias unique, either individually or by category, are the keys to identifying ventricular dysrhythmias. 1. Rhythm regularity: Check P-P and R-R intervals. Look for a relatively constant measurement from one interval to the next. No more than a small block and a half of variability is permitted when measuring P-P or R-R to still be able to call a pattern regular or constant. Page 3 of 26

2. Heart rate: Some dysrhythmias cause atrial (P waves) rates to be different from ventricular (QRS complex) rates. Count impulses for six seconds then multiply by 10 to determine an approximate heart rate. Both atrial and ventricular activity should be checked to ensure the rates are the same for both. 3. P wave: Is there a P wave for every QRS? Are they shaped the same? P waves with different shapes indicate different sources causing depolarization of the atria. 4. PR interval (PRI): Measure the PR interval. Certain dysrhythmias may cause the PR interval to shorten or lengthen. Normal range for PR interval is 0.12-0.20 seconds. 5. QRS complex width and appearance: Are QRS complexes present? Are the shapes the same from complex to complex? How do they measure? Normal range for QRS complex is 0.06-0.10 seconds. A measurement equal to or greater than 0.12 seconds indicates a ventricular conduction delay. If depolarization in the ventricles is delayed, it will cause the QRS to appear and measure wider than normal. HALLMARKS OF VENTRICULAR DYSRHYTHMIAS Rhythms that occur because of impulses from different regions of the heart alter the morphology of the cardiac complex. The hallmarks of ventricular dysrhythmias are the conspicuous absence of P waves and the presence of wide - bizarre QRS complexes that measure 0.12 seconds or greater in duration. After these are identified, the type of dysrhythmia present depends on the differences in the heart rate. Absent P Waves P waves are usually absent in ventricular dysrhythmias due to the timing of depolarization of the atria and ventricles. The portion of the heart with the greatest voltage (ventricles) will always be seen, rather than the small P wave (atria). Just because the P wave is not seen, it does not mean the atria are not depolarizing. Impulses coming from the ventricles typically travel in both an antegrade (forward) and retrograde (backward) manner. Wide Bizarre QRS Complexes The wide appearance (0.12 seconds or greater) of the QRS complex suggests both a delayed depolarization within the ventricles and a cell-by-cell depolarization. The bizarre appearance is caused by electrical impulses initiated within the ventricles that are coming from different impulse points and / or following different electrical conduction pathways. TYPES AND RATES OF VENTRICULAR DYSRHYTHMIAS This CE course will describe seven types of ventricular dysrhythmias: premature ventricular complexes, asystole, agonal, idioventricular, accelerated idioventricular, ventricular tachycardia, and ventricular fibrillation. One of the ways in which ventricular Page 4 of 26

dysrhythmias differ from one another is in their bpm rates. The table below lists the rates and types of ventricular dysrhythmias. Rhythm Rate in bpm Premature ventricular complexes Depends upon the underlying rhythm Asystole (flat line) 0 Agonal Less than 20 Idioventricular 20 40 Accelerated idioventricular 40 100 Ventricular tachycardia (V-tach or VT) 100 250 Ventricular fibrillation (V-fib or VF) 300 500 or more* *Technically in V-fib, the heart is not beating. The number range denotes electrical impulse activity. 1. Premature Ventricular Complexes Premature ventricular complexes (PVCs) are complexes that occur because of abnormal electrical impulses that come from the ventricles. These impulses occur earlier than anticipated, disrupting the underlying rhythm. The presence of PVCs causes the rhythm to be irregular. PVCs present with the classic wide and bizarre QRS (0.12 seconds or more), absent P wave, and T wave in the opposite direction of the ventricular depolarization. PVCs are very common and are felt by an individual as a palpitation or skipped heartbeat. The occasional appearance of PVCs in the absence of heart disease is not dangerous. The presence of PVCs in an individual with heart disease indicates increased excitability (irritability) in the heart, which may lead to ventricular fibrillation and sudden death. PVCs of one shape indicate that one location within the ventricles is irritated. PVCs of more than one shape, or couplet and triplet PVCs, can indicate irritability that is more widespread. The more frequent and variable shapes the PVCs are indicates more significant potential problem for the rhythm to convert to a more dangerous ventricular dysrhythmia. Additionally, frequent PVCs may cause signs and symptoms of low cardiac output, i.e. low blood pressure, pallor, nausea, confusion, etc. When analyzing any rhythm with premature complexes, the underlying rhythm must also be analyzed. Terminology Associated with PVCs TERM DEFINITION Unifocal PVCs of one shape Multifocal PVCs of two or more shapes Bigeminy Every 2 nd complex is a PVC Trigeminy Every 3 rd complex is a PVC Quadgeminy Every 4 th complex is a PVC Couplet Two PVCs back-to-back Triplet, run of V-tach, salvo Three PVCs in a row at a rate exceeding 100 beats per minute Occasional PVCs Five or less PVCs per minute Frequent PVCs Six or more PVCs per minute Page 5 of 26

ECG Tracings of Sinus Rhythm with PVCs Following are four examples of ECG tracings of PVCs in individuals with sinus (normal) heart rhythms. Example 1 Rhythm: Irregular Rate: 70 P Wave: Absent PR Interval: Absent QRS Complex: 0.08 seconds, early complexes wide and bizarre Interpretation: Sinus rhythm with unifocal PVCs Example 2 Rhythm: Irregular Rate: 60 P Wave: Absent PR Interval: Absent QRS Complex: 0.08 sec, early complexes wide and bizarre Interpretation: Sinus rhythm with multifocal PVCs Example 3 Page 6 of 26

Rhythm: Irregular Rate: 70 P Wave: Absent PR Interval: Absent QRS Complex: 0.08 sec, early complexes wide and bizarre Interpretation: Sinus rhythm with multifocal couplet PVCs Example 4 Rhythm: Irregular Rate: 80 P Wave: Absent PR Interval: Absent QRS Complex: 0.06 sec. early complexes wide and bizarre Interpretation: Sinus rhythm with a run of V-tach 2. Asystole Asystole means without contraction. If a tracing like the one below is seen on the cardiac monitor, the first thing to do is check the patient! If the patient is unresponsive, this is a medical emergency. It is treated with CPR and Advanced Life Support measures, including intubation, insertion of IV lines, and administration of cardiac medications. If the patient is able to speak, he/she is NOT in asystole. Common causes of an isoelectric line on a tracing in a patient who is not asystole include loose or disconnected leads, loss of power to the ECG monitor, and low signal gain on the ECG monitor. Rhythm: Absent Rate: 0 P Wave: Absent PR Interval: Absent QRS Complex: Absent Interpretation: Asystole Page 7 of 26

3. Agonal Agonal dysrhythmia is a type of ventricular rhythm seen when the rate is less than 20 beats per minute. It is seen as the last sign of organized electrical activity in a dying heart. A patient with an agonal rhythm will be unconscious. This is a medical emergency and resuscitative efforts (as described in asystole) are needed for the patient to live. Due to its slow rate, more than six seconds of tracing must be evaluated to determine if the rhythm pattern is regular or irregular. Note the absence of P waves, and the wide, bizarre QRS complexes. Rhythm: Regular Rate: 13 P Wave: Absent PR Interval: Absent QRS Complex: 0.20 sec, wide and bizarre Interpretation: Agonal 4. Idioventricular Idioventricular dysrhythmia may or may not be regular; the patient is likely to be unconscious. If the patient is conscious, he/she will be have signs and symptoms of low cardiac output. The rate is 20-40 beats per minute. Idioventricular rhythm may be seen in the last stage before asystole in a very sick patient and it may not respond to treatment. Note the absence of P waves, and the wide, bizarre QRS complexes. Rhythm: Regular Rate: 38 P Wave: Absent PR Interval: Absent QRS Complex: 0.30 sec, wide and bizarre Interpretation: Idioventricular Page 8 of 26

5. Accelerated idioventricular Accelerated idioventricular (AIVR) dysrhythmia may or may not be regular; the patient is likely to be conscious. It is seen in up to 20% of patients who have had an acute myocardial infarction. The patient will have signs and symptoms of low cardiac output at the lower end of the range. This patient may also show little if any loss of cardiac output due to the majority of the heart rate range mirroring the range of the SA node. However, the patient still requires close observation. Treatment is directed at identifying and treating the underlying cause of the accelerated ventricular rhythm. The rate is unusually broad, from 40-100 beats per minute. Notice the absence of P waves and the wide, bizarre QRS complexes. Rhythm: Regular Rate: 54 P Wave: Absent PR Interval: Absent QRS Complex: 0.18 sec, wide and bizarre Interpretation: Accelerated idioventricular 6. Ventricular tachycardia Ventricular tachycardia (V-tach) occurs when three or more PVCs occur in a row at a rate of 100 beats per minute. This is called a V-tach run, or sometimes a triplet or a salvo. A run of V-tach that lasts less than 30 seconds is called non-sustained. Sustained V-tach refers to rhythms that persist for 30 seconds or more. How the patient is treated depends on whether the rhythm is perfusing (contracting and moving blood) or not. Approximately half of ventricular tachycardia patients will become unconscious immediately. A pulseless apneic patient in V-tach must be immediately with treated with defibrillation. Two examples of ventricular tachycardia follow on the next page. Notice the absence of P waves, and the wide, bizarre QRS complexes. Page 9 of 26

Rhythm: Regular Rate: 150 P Wave: Absent PR Interval: Absent QRS Complex: 0.12 sec, wide and bizarre Interpretation: Ventricular tachycardia Rhythm: Regular Rate: 188 P Wave: Absent PR Interval: Absent QRS Complex: wide and bizarre, unable to determine baseline = no duration measurement Interpretation: Ventricular tachycardia 7. Ventricular fibrillation Ventricular fibrillation (V-fib) is identified by chaotic electrical activity and absence of the organized PQRST. If the fibrillating heart could be visualized, it would appear to quiver rather than alternately contract the atria then the ventricles. The electrical activity is very rapid and not coordinated between small groups of cells. V-fib is categorized as fine (waveforms less than 3 mm) or coarse (waveforms greater than 3 mm). Because of the electrical chaos, the chambers of the heart are not contacting and moving blood as usual. This is a true medical emergency; the patient will be unconscious, and requires immediate defibrillation for he/she to survive. If this pattern is seen on an ECG monitor, and the patient is alert and speaking, he/she is NOT in V-fib. Loose, dried out electrodes, damaged cables, etc., may create a tracing similar to V-fib. Notice the absence of PQRST complexes in the example of V-fib on the following page. Page 10 of 26

Rhythm: Irregular, chaotic Rate: Unable to determine P Wave: Absent PR Interval: Absent QRS Complex: Absent Interpretation: Ventricular fibrillation CAUSES AND TREATMENTS FOR VENTRICULAR DYSRHYTHMIAS Ventricular dysrhythmias can have cardiac and noncardiac causes. Cardiac causes: acute and chronic ischemic heart disease, cardiomyopathy, valvular heart disease, and mitral valve prolapse. Noncardiac causes: stimulants such as caffeine, cocaine, and alcohol; metabolic abnormalities such as hypoxemia, hyperkalemia, hypokalemia, and hypomagnesemia. Drugs used to treat ventricular dysrhythmias include digoxin, theophylline, antipsychotics, tricyclic antidepressants, and antiarrhythmic specific drugs that have proarrhythmic potential (flecainide, dofetilide, sotalol, and quinidine). If medications do not work to control a ventricular dysrhythmia, a pacemaker or an implantable cardioverter-defibrillator (ICD) may be implanted. A pacemaker will keep a heart from beating too slowly. An ICD monitors heart rhythm and, if it detects a very fast, abnormal rhythm, it shocks the heart muscle to convert it back to normal rhythm. In some cases, catheter ablation may be performed. This is a surgical procedure where electrical energy is delivered via a catheter to a small area of tissue inside the heart that causes the dysrhythmia. This eliminates the electrical pathway of the abnormal rhythm, allowing the heart to beat normally. CONCLUSION This CE course has described ventricular dysrhythmias, including unique features, analysis, interpretation of ECG strips, causes, and treatments. Ventricular dysrhythmias are unique and potentially dangerous. Two types of ventricular dysrhythmias, V-tach and V-fib, may require defibrillation to restore normal cardiac rhythm to allow the patient to live. Page 11 of 26

REFERENCES Accelerated Idioventricular Rhythm. Medscape Reference. 13 April 2010. Web. Accessed 10 May 2011. Accelerated Idioventricular Rhythm: History and Chronology of the Main Discoveries. Indian Pacing and Electrophysiology Journal. 2010. Web. Accessed 10 May 2011. Kathryn A. Booth, Thomas E. O Brien, Electrocardiography for Healthcare Professionals; 3 rd edition, McGraw-Hill Publishing, New York, New York, 10020-1095. Heart Disease and Abnormal Heart Rhythm. MedicineNet.com. 7 March 2009. Web. Accessed 10 May 2011. Management of Common Arrhythmias: Part II. Ventricular Arrhythmias and Arrhythmias in Special Populations. American Family Physician. 15 June 2002. Web. Accessed 6 May 2011. TEST QUESTIONS Ventricular Dysrhythmias #1220911 Directions: Before taking this test, read the instructions on how to complete the answer sheets correctly. If taking the test online, log in to your User Account on the NCCT website at www.ncctinc.com. Select the response that best completes each sentence or answers each question from the information presented in the module. If you are having difficulty answering a question, go to www.ncctinc.com and select Forms/Documents. Then select CE Updates and Revisions to see if course content and/or test questions have been revised. If you do not have access to the internet, call Customer Service at 800-875-4404. 1. Which of the following dysrhythmias has chaotic waveforms, no identifiable P waves or QRS complexes, and no rate? a. Accelerated idioventricular b. Asystole c. Ventricular fibrillation d. Ventricular tachycardia 2. Which of the following dysrhythmias has regular rhythm, ventricular rate > 100 bpm, QRS duration greater than or equal to 0.12 seconds and no P waves? a. Accelerated idioventricular b. Asystole c. Ventricular fibrillation d. Ventricular tachycardia Page 12 of 26

3. Which of the following dysrhythmias has no P waves, wide and bizarre QRS complexes, and a rate less than 20 bpm? a. Agonal b. Asystole c. Idioventricular d. Ventricular tachycardia 4. Which of the following dysrhythmias has no P waves, wide and bizarre QRS complexes, and a rate between 40-100 bpm? a. Accelerated idioventricular b. Asystole c. Idioventricular d. Ventricular tachycardia 5. Which of the following dysrhythmias has no P waves or QRS complexes, and a flat line? a. Accelerated idioventricular b. Asystole c. Ventricular fibrillation d. Ventricular tachycardia 6. Which of the following morphologic features are seen in ventricular dysrhythmias? a. Missing P wave, elevated T wave b. Missing P wave, wide and bizarre QRS c. Narrow QRS, inverted P wave d. Wide QRS and biphasic P wave 7. Which pacemaker site in the heart is associated with ventricular dysrhythmias? a. Atrial internodal pathways b. AV Junction c. Purkinje fibers d. SA node Continue to next page. Page 13 of 26

8. Identify the cardiac rhythm / dysrhythmia seen on the following ECG strip. a. Sinus rhythm with bigeminy multifocal PVC b. Sinus rhythm with monogeminy couplet PVC c. Sinus rhythm with a run of V-tach d. Sinus rhythm with multifocal couplet PVC 9. Identify the cardiac rhythm / dysrhythmia seen in the following ECG strip. a. Accelerated idioventricular b. Idioventricular c. Ventricular fibrillation d. Ventricular tachycardia 10. Identify the cardiac rhythm / dysrhythmia seen on the following ECG strip. a. Accelerated idioventricular b. Idioventricular c. Ventricular fibrillation d. Ventricular tachycardia Page 14 of 26

11. Identify the abnormal feature seen on this rhythm strip. a. Bigeminy multifocal PVC b. Monogeminy couplet PVC c. Multifocal couplet PVC d. Run of V-tach 12. Identify the cardiac rhythm / dysrhythmia seen on the following ECG strip. a. Accelerated idioventricular b. Idioventricular c. Ventricular fibrillation d. Ventricular tachycardia 13. Identify the pattern and morphology seen on the following ECG strip. a. Quadgeminy multifocal b. Quadgeminy unifocal c. Trigeminy multifocal d. Trigeminy unifocal Page 15 of 26

14. Identify the pattern and morphology seen on the ECG strip below. a. Artifact from loose electrodes b. Couplet unifocal PVCs c. Salvo PVCs d. Trigeminy unifocal PVCs 15. Identify the pattern and morphology seen on the ECG strip below. a. Sinus rhythm with PAC b. Sinus rhythm with PJC c. Sinus rhythm with PVC d. Sinus rhythm with loose electrode Continue to next page. Page 16 of 26

16. The pacemaker site of electrical stimulation causing ventricular depolarization on this tracing is the. a. AV Junction b. Interatrial pathways c. Purkinje fibers d. SA Node 17. Identify the dysrhythmia present on the ECG strip in question 16. a. Agonal b. Asystole c. Idioventricular d. Ventricular fibrillation 18. Identify the cardiac rhythm / dysrhythmia seen on the following ECG strip. a. Accelerated idioventricular b. Idioventricular c. Ventricular fibrillation d. Ventricular tachycardia 19. If the patient with the ECG tracing in question 18 is still talking to you, you should. a. call a Code Blue b. charge the defibrillator c. check the ECG electrodes d. start CPR Page 17 of 26

20. Identify the abnormal complexes seen on the following ECG strip. a. Bigeminy PVCs b. Couplet PVCs c. Multifocal PVCs d. Unifocal PVCs 21. Identify the cardiac rhythm / dysrhythmia seen on the following ECG strip. a. Accelerated idioventricular b. Sinus bradycardia with PVC c. Sinus rhythm with PVC d. Ventricular bradycardia 22. Identify the cardiac rhythm / dysrhythmia seen on the following ECG strip. a. Agonal b. Asystole c. Idioventricular d. Ventricular fibrillation Page 18 of 26

23. How are patients with the dysrhythmia seen in question 22 initially treated? a. Check the patient, call Code Blue, perform CPR and ALS measures, and give cardiac medications b. Check the patient, call Code Blue, perform immediate cardioversion c. Check the patient, call Code Blue, perform immediate defibrillation d. Check the patient, call a Code Blue, terminate resuscitative efforts 24. Identify the cardiac rhythm / dysrhythmia seen in the following ECG strip. a. Accelerated idioventricular b. Agonal c. Idioventricular d. Ventricular tachycardia 25. Select the most accurate description of the waveforms in the ECG strip below. a. Asystolic and fine b. Coarse and chaotic c. Organized and coarse d. Wide and bizarre Page 19 of 26

26. Which of the following terms refers to the forward movement of the electrical impulse? a. Antegrade b. Coarse c. Ventricular d. Retrograde 27. Which of the following terms refers to the backward movement of the electrical impulse? a. Antegrade b. Coarse c. Idioventricular d. Retrograde 28. PVCs occurring every other beat are called. a. Bifocal b. Bigeminy c. Mongeminy d. Monofocal 29. PVCs occurring every fourth beat are called. a. Quadgeminy b. Quadfocal c. Run of ventricular tachycardia d. Salvo 30. PVCs occurring every third beat are called. a. Trifocal b. Trigeminy c. Multifocal d. Salvo 31. Cardiac rhythms lasting greater than 30 seconds are called. a. Asystole b. Coarse c. Non-sustained d. Sustained 32. P waves in ventricular dysrhythmias are described as. a. Absent b. Biphasic c. Inverted d. Upright and rounded Page 20 of 26

33. QRS complexes in ventricular dysrhythmias are described as. a. narrow b. negative only c. positive only d. wide and bizarre 34. Fibrillatory activity is often described as either. a. antegrade or retrograde b. sustained or non-sustained c. present or absent d. coarse or fine 35. The T wave in ventricular complexes is direction of the QRS complex. a. absent b. biphasic c. in the opposite d. in the same 36. A salvo is defined as PVCs in a row. a. two b. three c. four d. five 37. A non-sustained rhythm is one the lasts. a. less than 30 seconds b. less than 60 seconds c. more than 20 seconds d. more than 30 seconds 38. Coarse fibrillatory waves measure. a. greater than 3.0 mm b. greater than 5.0 mm c. less than 4.0 mm d. less than 10.0 mm 39. Which of the following is an abnormal QRS duration? a. 0.06 sec b. 0.08 sec c. 0.10 sec d. 0.12 sec Page 21 of 26

40. What is the first thing you should do when you recognize a dysrhythmia on the patient s heart monitor? a. Call a Code Blue b. Charge the defibrillator c. Check the patient d. Call the patient s nurse 41. Identify the cardiac rhythm / dysrhythmia seen in the following ECG strip. a. Sinus tachycardia with a run of ventricular tachycardia b. Sinus tachycardia with multifocal couplet PVC (paroxysmal) into ventricular tachycardia c. Sinus tachycardia into ventricular fibrillation d. Sinus tachycardia into ventricular tachycardia 42. Identify the cardiac rhythm / dysrhythmia seen in the following ECG strip. a. Agonal b. Ventricular fibrillation c. Ventricular tachycardia d. Ventricular tachycardia (paroxysmal)into ventricular fibrillation Page 22 of 26

43. Identify the cardiac rhythm / dysrhythmia seen in the following ECG strip. a. Agonal b. Asystole c. Idioventricular d. Ventricular Fibrillation 44. Identify the cardiac rhythm / dysrhythmia seen in the following ECG strip. a. Agonal b. Asystole c. Idioventricular d. Ventricular fibrillation Continue to next page. Page 23 of 26

45. Identify the cardiac rhythm / dysrhythmia seen in the following ECG strip. a. Sinus rhythm with multifocal bigeminy PVCs b. Sinus rhythm with multifocal couplet PVCs c. Sinus rhythm with unifocal couplet PVCs d. Sinus rhythm with unifocal quadgeminy PVCs 46. Identify the cardiac rhythm / dysrhythmia seen in the following ECG strip. a. Accelerated idioventricular b. Agonal c. Ventricular tachycardia d. Idioventricular Continue to next page. Page 24 of 26

47. Identify the cardiac rhythm / dysrhythmia seen in the following ECG strip. a. Sinus rhythm with bigeminy multifocal PVCs b. Sinus rhythm with bigeminy unifocal PVCs c. Sinus rhythm with monogeminy multifocal PVCs d. Sinus rhythm with monogeminy unifocal PVCs 48. The abnormal feature seen on the ECG strip below is referred to as. a. Agonal b. Idioventricular rhythm c. Triplet PVCs d. Trigeminy unifocal PVCs Page 25 of 26

49. This rhythm is when measuring the R - R intervals. a. Agonal b. Coarse c. Irregular d. Regular 50. What is the most accurate heart rate in following ECG tracing? a. 85 b. 130 c. 170 d. 200 *end of test* Page 26 of 26