Dysrhythmia Identification
A rhythm strip shows:
Rate less than 60
Regular rhythm
P wave before every QRS
Normal PR interval
Narrow QRS
Patient is asymptomatic.
What rhythm is this and do you treat?
Sinus bradycardia.
If asymptomatic → monitor only.
If symptomatic → Atropine.
A rhythm strip shows:
PR interval prolonged (>0.20 sec)
Every P wave followed by a QRS
Rhythm regular
What rhythm is this and what is the treatment?
First-degree AV block.
Usually monitor only.
No immediate treatment unless symptomatic.
A patient suddenly develops:
Acute shortness of breath
Pleuritic chest pain
Tachycardia
They had surgery 3 days ago.
What condition are you most concerned about?
Pulmonary embolism.
Classic risk factor = recent surgery + immobility.
Sudden dyspnea + chest pain + tachycardia = red flag.
A trach patient becomes restless with decreasing SpO₂ and you hear a high-pitched sound from the trach.
What is the likely problem and first action?
⭐ Bonus: If suctioning does not resolve the issue, what is your next step?
Likely trach obstruction (mucus plug).
First action → Suction the trach.
⭐ Bonus Answer:
If unresolved → Remove inner cannula and replace it.
If still compromised → Prepare for emergency airway support.
Chaotic waveform, no identifiable QRS complexes.
Shockable or not?
⭐ Bonus: Why?
Shockable (ventricular fibrillation).
⭐ Bonus Answer:
There is disorganized electrical activity that can be reset by defibrillation.
A rhythm strip shows:
Rate greater than 100
Regular
P wave before each QRS
Narrow QRS
Patient has fever and pain.
What rhythm is this and what is the treatment?
Sinus tachycardia.
Treat the underlying cause (pain, fever, hypoxia).
Do NOT cardiovert.
A rhythm strip shows:
PR interval gets longer… longer… longer…
Then a QRS complex is dropped
Pattern repeats
What rhythm is this and how is it typically managed?
Second-degree AV block Type I (Wenckebach).
Usually monitor.
If symptomatic → Atropine.
Hallmark: “Longer, longer, longer, drop.”
What is the most common source of a pulmonary embolism?
Deep vein thrombosis (DVT) from the lower extremities.
Clot travels through venous system → right heart → pulmonary arteries.
A trach becomes dislodged and it is less than 7 days old.
What should you do?
⭐ Bonus: Why is reinsertion dangerous at this stage?
Do NOT blindly reinsert.
Call for help.
Provide oxygen via bag-mask over mouth and stoma.
⭐ Bonus Answer:
The stoma is not mature yet and can close quickly or create a false passage.
Flat line on monitor.
Shockable or not?
⭐ Bonus: What medication is given?
Not shockable (asystole).
⭐ Bonus Answer:
Epinephrine.
A rhythm strip shows:
Irregularly irregular rhythm
No distinct P waves
Narrow QRS
What rhythm is this and what is the biggest complication risk?
Atrial fibrillation.
Biggest risk = stroke.
Stable → rate control + anticoagulation.
Unstable → synchronized cardioversion.
A rhythm strip shows:
PR intervals are constant
Suddenly a QRS complex is dropped
Rhythm otherwise regular
What rhythm is this and what is the priority treatment?
Second-degree AV block Type II.
More serious than Type I.
Priority treatment → Pacing.
A patient is suspected of PE. Which diagnostic test is most definitive?
CT pulmonary angiography (CTPA).
D-dimer may be elevated but is nonspecific.
CTPA confirms clot in pulmonary arteries.
A trach patient develops neck swelling, crepitus, and respiratory distress.
What complication is occurring?
⭐ Bonus: What intervention may be required?
Possible pneumothorax or tracheal injury.
⭐ Bonus Answer:
Chest tube placement may be required if pneumothorax confirmed.
Wide-complex tachycardia with pulse, BP 78/40.
Stable or unstable?
What is the intervention?
⭐ Bonus: If pulse is lost?
Unstable → Synchronized cardioversion.
⭐ Bonus Answer:
If pulse lost → Defibrillate + CPR.
A rhythm strip shows:
Sawtooth baseline
Regular rhythm
Narrow QRS
What rhythm is this and how is it treated if unstable?
Atrial flutter.
If unstable → synchronized cardioversion.
Stable → rate control.
A rhythm strip shows:
P waves regular
QRS complexes regular
No relationship between P waves and QRS
Ventricular rate slow
What rhythm is this and what is the treatment?
Third-degree (complete) heart block.
Treatment → Transcutaneous pacing → permanent pacemaker.
A patient with confirmed PE is hemodynamically stable.
What is the first-line treatment?
Anticoagulation (e.g., Heparin).
Purpose: Prevent clot extension and new clot formation.
Ventilator high-pressure alarm is sounding.
What does this indicate?
⭐ Bonus: What is the FIRST thing you assess?
High pressure = obstruction or increased resistance.
Think:
• Secretions
• Kinked tubing
• Biting tube
• Pneumothorax
⭐ Bonus Answer:
Assess the patient first, not the machine.
Narrow-complex tachycardia around 180 bpm, BP stable.
First intervention?
⭐ Bonus: If vagal maneuvers fail?
Vagal maneuvers.
⭐ Bonus Answer:
Adenosine (rapid IV push + flush).
A rhythm strip shows:
Very fast rate (150–250 range)
Regular rhythm
P waves not visible
Narrow QRS
What rhythm is this and what is the first intervention if stable?
Supraventricular tachycardia (SVT).
First intervention if stable → Vagal maneuvers.
If ineffective → Adenosine.
If unstable → synchronized cardioversion.
A rhythm strip shows:
Wide QRS complexes
Fast rate
Regular rhythm
P waves absent
Patient is hypotensive and altered.
What rhythm is this and what is the immediate intervention?
Ventricular tachycardia (unstable).
Immediate intervention → Synchronized cardioversion.
If pulseless → Defibrillation + CPR.
A patient with PE becomes:
Hypotensive
Tachycardic
Altered
Increasing hypoxia
What complication is occurring and what treatment may now be required?
Massive PE causing obstructive shock.
Treatment:
• Thrombolytics (if no contraindications)
• Possible thrombectomy
This is life-threatening and requires immediate intervention.
Ventilator low-pressure alarm is sounding.
What does this indicate?
⭐ Bonus: What life-threatening situation must you rule out?
Low pressure = disconnection or air leak.
⭐ Bonus Answer:
Accidental extubation.
Which patient do you see first?
A) Stable A-fib HR 120
B) Complete heart block HR 34, BP 86/52
C) Stable PE on heparin
D) Sinus tach HR 110 with fever
⭐ Bonus: Why not the PE patient?
B.
Severe bradycardia + hypotension = immediate perfusion threat.
⭐ Bonus Answer:
The PE patient is currently stable; heart block with hypotension is an immediate risk for cardiac arrest.