NINE MOST COMMON ECG

STRIPS
HOPE LULET A. LOMIOAN, PHRN, MSN, USRN
College Instructor/Academic Coordinator
STCI College of Nursing
NORMAL SINUS
RHYTHM
• Treatment:
• None – continue to monitor patient

• Causes:
• Being healthy
BRADYCARDIA
• Treatment:
• Atropine ONLY if symptomatic,
showing low perfusion (pale, cool,
clammy)

• Causes:
• Vagal maneuver (bearing down),
medications (CCB, Beta Blockers)
VENTRICULAR
FIBRILLATION (V Fib)
• Treatment:
• V fib – Defib #1: Defibrillation immediately. Stop
CPR, defib before drugs!
• NO synchronization needed
• Drugs: L. A. P. > Lidocaine, Amiodarone,
Procainamide

• Causes:
• Untreated Vtach, Post MI
• E+ Imbalance, proarrhythmic medications
 VENTRICULAR
TACHYCARDIA (V Tach)
• Causes:
• Post MI
• Hypoxia
• Low potassium
• Low magnesium

• Treatment:
1. Early Defibrillation (NCLEX TIP) MEMORY TRICKS
• Apply defibrillator pads C – Count a pulse
• Call out and look for everyone to be C – Cardiovert
CLEAR • Synchronize First then Sedate
• Shock and IMMEDIATELY continue
chest compressions.
2. When to Shock? (NCLEX TIP) D – Dead – No pulse
• V Tach with No pulse = Defibrillation D – Defib!
• V Tach with Pulse = Cardioversion • NO Synchronize
• D – Don’t wait!
 ATRIAL FIBRILLATION (A Fib)
• Causes:
• Valvular disease
• Heart failure
• Pulmonary hypertension 3. Anticoagulants: Warfarin, (monitor INR,
• COPD Vit. K as antidote, moderate green leafy
• Post-cardiac surgery vegetables
• Treatment: 4. Calcium Channel Blockers:
1. Cardioversion (after TTE to rule out clots) DILTIAZEM NCLEX TIP
* Push Synch
2. Digoxin – Deep Contraction
Check ATP before giving:
A – Apical pulse 60
T – Toxicity (Max 2.0 range) visual
disturbances, N/V and anorexia
P - Potassium below 3.5 – HIGHER RISK
FOR TOXICITY NCLEX TIP
ATRIAL FLUTTER
• Causes:
• Valvular disease
• Heart Failure
• Pulmonary hypertension
• COPD
• Cardiac surgery
• Treatment:
1. Cardioversion (after TTE to rule out clots)
*Push Synch
2. Digoxin – Deep Contraction
Check ATP before giving
A – Apical Pulse 60
T – Toxicity
P – Potassium
3. Anticoagulants: Warfarin
SUPRAVENTRICULAR TACHYCARDIA
• Causes:
• Stimulants, strenuous exercise, hypoxia,
heart disease
• Treatment: KAPLAN QUESTION
1. Vagal Maneuver (bear down like Which medication should be held 48-hours prior to
having a bowel movement, ice cold an elective cardioversion for SVT?
stimulation
2. Adenosine – RAPID PUSH and flush • Digoxin due to increased ventricular irritability
with Normal Saline – HR may stop
Client with SVT has the following assessment data:
3. Cardioversion – Push Synch HR 200, BP 78/40, RR 30.

• Priority action: Synchronized cardioversion

TORSADES • Causes:
• Post MI, Hypoxia, Low Magnesium

DE POINTES • Treatment:
• Magnesium Sulfate NCLEX TIP
ASYSTOLE - • Epinephrine, Atropine and CPR

Flatline • NO Defibrillation
(NO Shock) NCLEX TIP
NCLEX Key Terms
 Let’s Try
These
Questions
1. Based on the ECG rhythm, what A. Labetalol
should the nurse administer? B. Atropine
C. Adenosine
D. Digoxin
The correct answer is B.
Atropine sulfate is the drug of choice for sinus bradycardia. Atropine is a vagolytic;
it reduces vagal stimulation and increases heart rate.
A is incorrect. Among the adverse effects of labetalol, which is a beta blocker,
include orthostatic hypotension, bronchospasm (the drug should be avoided in asthma
patients), heart failure, and significant bradycardia (it should be avoided in the presence of
sinus bradycardia or heart block greater than the first degree). Hence, labetalol is
contraindicated for the patient.
C is incorrect. Adenosine is a prescription medication used for conversion to sinus
rhythm of paroxysmal supraventricular tachycardia (PVST), including that associated with
accessory bypass tracts (Wolff-Parkinson-White Syndrome). Adenosine is contraindicated
in patients with sinus node disease, such as sick sinus syndrome or symptomatic
bradycardia, and in patients with second- or third-degree atrioventricular (AV) block.
D is incorrect. Digoxin is indicated for use in patients with heart failure, atrial
flutter, atrial fibrillation, and to induce fetal demise prior to abortion. However, digoxin is
used with caution in patients with sinus bradycardia.
2. The nurse sees the following 6-second ECG
a. Propranolol
rhythm on a client who is newly admitted for acute
b. Atropine sulfate
exacerbation of bronchial asthma. The nurse should
c. Epinephrine
prepare to administer which of the following
d. Metoprolol
medications?
The correct answer is D.
D is correct. The ECG rhythm shows sinus tachycardia, a heart
rate of 130 bpm. A beta blocker can be given to reduce the heart rate.
Metoprolol is a cardioselective beta-blocker, which means that it blocks
beta-1 receptors (reduce heart rate) but does not affect beta-2
receptors (maintains bronchodilation).
A is incorrect. Blocking the beta-2 receptors, an effect of non-
selective beta-blockers such as propranolol, will cause
bronchoconstriction and can aggravate the asthma.
B and C are incorrect. Atropine sulfate and epinephrine can
further worsen the tachycardia as both drugs increase cardiac rate.
3. The nurse enters the client’s a. Open the airway.
room and found the patient b. Give rescue breaths.
unconscious and pulseless
with this ECG rhythm. What is c. Give chest compressions
the first action of the nurse? d. Call the physician
The correct answer is C.
The patient's condition reveals pulseless ventricular fibrillation.
Pulseless ventricular fibrillation is treated with defibrillation if an
automated external defibrillation (AED) is available. If not, cardiopulmonary
resuscitation (CPR) is initiated immediately. Initiate effective chest
compressions at 100-120 per minute, at least 2 inches deep.
A and B are incorrect. Opening the airway and giving rescue breaths
are not the priority interventions in the patient's condition. In performing
CPR, remember that instead of ABC (airway, breathing, circulation), the
sequence is now CAB (circulation, airway and then breathing).
D is incorrect. Calling the physician would not be the priority and best
life-saving intervention in this scenario.
4.
Which of the following ECG
deflections or waveforms in the
photo reflects depolarization of
the atria?

Fill in the blank:

__________________________
The correct answer is P wave.
5.

Identify the following cardiac

dysrhythmia.

a. Ventricular asystole
b. Ventricular fibrillation
c. Premature ventricular
contractions
d. Ventricular tachycardia
D is correct.
The rhythm shown is a ventricular tachycardia. In ventricular
tachycardia, heartbeat is fast and regular. Ventricular tachycardia is
characterized by very broad QRS complexes with uniform morphology.
A is incorrect. Ventricular asystole is characterized by a flat line, which
signifies the cessation of electrical and mechanical activity of the heart.
B is incorrect. In ventricular fibrillation, heartbeat is fast and irregular.
It shows irregular waves with varying morphology and amplitude. No P wave,
QRS complex, or T-wave can be seen.
C is incorrect. Premature ventricular contractions (PVCs) are extra
heartbeats that begins from the ventricles. It is characterized by prematurely
and bizarrely shaped QRS complexes that are unusually long (typically >120
msec) and appear wide on the ECG.
6. A client is diagnosed with cardiac a. Magnesium sulfate
dysrhythmia shown below. Which of the b. Diltiazem
following should the nurse administer? c. Lidocaine
d. Atropine sulfate
The answer is B.
The rhythm shown on the ECG strip suggests atrial fibrillation. The
initial drug of choice for atrial fibrillation is diltiazem. Diltiazem is a calcium
channel blocker that relaxes blood vessels and eases the heart’s workload.
Diltiazem is prescribed for patients with atrial fibrillation primarily for its
ability to control the ventricular rate by slowing conduction through the AV
node. This helps manage symptoms associated with rapid heart rates, reduces
the risk of tachycardia-induced cardiomyopathy, and provides an alternative
option for rate control. Careful dosage adjustment and monitoring are
necessary to ensure effective and safe management of atrial fibrillation with
diltiazem.
7. Which of the following medications is given to a. Warfarin
prevent major complication associated with the b. Labetalol
above shown cardiac dysrhythmia?
c. Nitroglycerin
d. Digoxin
The correct answer is A.
The ECG strip shows atrial fibrillation. Blood clot in the atria is the major
and most severe complication of atrial fibrillation. Anticoagulants such as warfarin
is prescribed to prevent blood clots.
B is incorrect. Although labetalol is a beta-blocker, which counts among the
primary medications indicated for ventricular rate control during atrial fibrillation,
labetalol does not prevent in blood clot formation.
C is incorrect. Administering nitroglycerin in the occurrence of atrial
fibrillation increases the risks for adverse reactions such as hypotension and
pulmonary congestion. While blood clots in the atria is the major and most severe
complication of atrial fibrillation, nitroglycerin does not prevent blood clot
formation.
D is incorrect. Although digoxin still counts among the most frequently
prescribed medications in the management if atrial fibrillation, digoxin's main
indications for atrial fibrillation include the restoration of normal sinus rhythm,
prevention of recurrence and slowing of the ventricular rate. Digoxin does not
prevent blood clot formation in the atria.
8. Match column A with column B
Column A Column B
1. P wave 1. Rapid ventricular depolarization
2. QRS complex 2. Ventricular repolarization
3. T wave 3. Atrial depolarization
4. P-Q interval 4. Conduction time from the beginning of atrial excitation to the
5. S-T segment beginning of ventricular excitation
6. Q-T interval 5. Time from the beginning of ventricular depolarization to the end
of ventricular repolarization.
6. Time when the ventricular contractile fibers are depolarized
during the plateau phase of the action potential.
Answer:
The P wave indicates atrial depolarization. The P wave occurs when the sinus node, also known as
the sinoatrial node, creates an action potential that depolarizes the atria. The P wave should be upright in lead
II if the action potential is originating from the SA node. In this setting, the ECG is said to demonstrate a normal
sinus rhythm, or NSR. As long as the atrial depolarization is able to spread through the atrioventricular, or AV,
node to the ventricles, each P wave should be followed by a QRS complex.
A combination of the Q wave, R wave and S wave, the “QRS complex” represents ventricular
depolarization. This term can be confusing, as not all ECG leads contain all three of these waves; yet a “QRS
complex” is said to be present regardless. For example, the normal QRS complex in lead V1 does not contain a
Q wave — only a R wave and S wave — but the combination of the R wave and S wave is still referred to as the
QRS complex for this lead. The normal duration (interval) of the QRS complex is between 0.08 and 0.10
seconds — that is, 80 and 100 milliseconds. When the duration is between 0.10 and 0.12 seconds, it is
intermediate or slightly prolonged. A QRS duration of greater than 0.12 seconds is considered abnormal.
The T wave occurs after the QRS complex and is a result of ventricular depolarization. T waves
should be upright in most leads (except aVR and V1). T waves should be asymmetric in nature. The second
portion of the T wave should have a steeper decline when compared to the incline of the first part of the T
wave. If the T wave appears symmetric, cardiac pathology may be present such as ischemia.
The P-Q interval (also known as PR interval) represents the time for conduction from the SA node
across the AV node and His-Purkinje system. Normal values for the PQ interval in horses vary considerably
because of high resting parasympathetic tone.
The Q-T interval is the time between the onset of ventricular depolarization and the end of
ventricular repolarization.
The S-T interval is the time between the end of the S-wave and the beginning of the T-wave.
9. What is the first nursing action upon seeing this a. Administer epinephrine
cardiac rhythm on the monitor?
b. Initiate chest
compressions
c. Defibrillate immediately
d. Ensure a patent airway
The correct answer is B.
For asystole, perform cardiopulmonary resuscitation (CPR)
immediately.
A is incorrect. Epinephrine may be given after initial rounds of
CPR.
C is incorrect. Do not defibrillate asystole as there is no electrical
impulse in the heart. Defibrillation is only indicated in ventricular
tachycardia or ventricular fibrillation.
D is incorrect. Latest CPR guidelines prescribe C-A-B (circulation,
airway and then breathing), not anymore A-B-C (airway, breathing and
then circulation). Hence, ensuring a patent airway is no longer the
priority.