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Diagnostics and Technology Case Study Module 1 (15 points)

Please read the case study and evaluate at the corresponding EKG strips. All EKG strips are 6 second strips.
Please answer all corresponding questions.

1. This patient presents to the ED with CO chest pain and dyspnea. While awaiting the 12 lead EKG the
CNP looks at the monitor and interprets strip A. Normal Sinus Rhythm rate of 80.

2. Would this rhythm require any treatment? If so, what? No, this is a normal rhythm. A health history
(medical/social/familial) and information about presentation of would be helpful. Vital signs, a chest X-
Ray, D-Dimer, and cardiac enzymes may be indicated to rule out PE or a cardiovascular event. 325 mg
Aspirin and 0.4 mg of sublingual nitroglycerin every 5 minutes x3 doses may be given.

Strip A

1. The patient presents to your urgent care with complaints of dizziness and dyspnea. She has no complaints
of chest pain. After hooking her up to the monitor the CNP interprets strip B as: Sinus Bradycardia rate of
40.

2. Would this rhythm require any treatment? If so, what? Yes. According to the American Heart Association
(AHA) Adult Bradycardia algorithm, hemodynamically unstable or symptomatic bradycardia would be
treated by, “Maintain patent airway; assist breathing as necessary, Oxygen if hypoxemic, monitor blood
pressure and oximetry, IV access, 12-Lead ECG if available; consider possible hypoxic and toxicologic
causes”. The mediation of choice would be Atropine IV First dose: 1 mg bolus. Repeat every 3-5 minutes.
Maximum: 3 mg. If Atropine ineffective transcutaneous pacing or dopamine infusion may be necessary.
Dopamine IV infusion: Usual infusion rate is 5-20 mcg/kg per minute. Consult to Cardiology. (American
Heart Association, 2020)

Strip B
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1. This patient presents to the ED with CO chest pain and a “racing heart”. While awaiting the 12 lead EKG
the CNP looks at the monitor and interprets strip C. as: Supraventricular Tachycardia rate of 180.
2. Would this rhythm require any treatment? If so, what? In addition to, “identifying cause maintaining a
patent airway, oxygen if hypoxemic, IV access, and blood pressure and oximetry monitoring”, the AHA
Tachycardia with a pulse recommends for hemodynamically stable SVT, “Vagal maneuvers and
Adenosine 6 mg IV rapid push and a Second dose of 12 mg if needed, and Beta Blockers/Calcium
Channel Blockers. Cardiology Consult.” Synchronized cardioversion is needed for any signs of
hemodynamic instability such as hypotension and altered mental status. Consult to Cardiology.
(American Heart Association, 2020)

Strip C

1. The CNP is making rounds on Saturday morning and while assessing the telemetry patient, the CNP
notices the dysrhythmia. The CNP looks at the monitor and interprets strip D. as: Sinus Rhythm with
Unifocal Trigeminy PVC’s rate of 50.
2. Would this rhythm require any treatment? If so what? This rhythm does require some attention such
as continued cardiac monitoring and a serum potassium. Although they are unifocal, their morphology
is the same, and they are occurring well after the T wave, this rhythm still places the patient at high risk
for developing Ventricular Tachycardia due to them occurring at a rate of greater than 6 per minute. If
there are no other causes (stress, anxiety, hypokalemia) the patient could be treated with an
antiarrhythmic such as amiodarone. Cardiology consult.
3. What are common causes of this dysrhythmia? Common causes of PVC’s include hypoxia, hypokalemia,
caffeine, and stress.

Strip D
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1. This patient presents to the primary care office for a routine physical. He has no symptoms. After
running a strip on this patient, the CNP interprets strip E. as: Sinus Rhythm with 1st Degree AVB rate of
70.
2. Would this rhythm require any treatment? If so, what? If the patient is hemodynamically stable and
remains asymptomatic, no treatment is needed.

Strip E

1. You’re the hospitalist on call for the step-down unit on night shift. The nurse calls you because her
patient is not responding. The CNP looks at the telemetry monitor and strip F. as: Ventricular
Tachycardia rate of 160.
2. Would this rhythm require any treatment? If so, what? Assuming the patient is pulseless
(unresponsive), a Code Blue needs to be called. Defibrillation needs to occur as soon as possible, and
CPR needs to be initiated immediately until the defibrillator is available. Following ACLS guidelines
from the AHA CPR with pulse check/AED check/shock if needed every 2 minutes, and Epinephrine IV
push 1 mg every 3-5 minutes. If the rhythm is shockable, Amiodarone or Lidocaine can be given.
Amiodarone IV 300 mg; Second dose: 150 mg. Lidocaine IV 1-1.5 mg/kg; Second dose: 0.5-0.75 mg/kg.
An advanced airway needs to be inserted. Reversable causes need to be considered H’s and T’s. Notify
the family. (American Heart Association, 2020)
Strip F
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1. The CNP is the team leader on the “code blue team”. After responding to a code, you see this on the
monitor. The CNP interprets strip G. as: Ventricular Fibrillation
2. What are the first 3 things you would do? Defibrillate, CPR, Epinepherine

Strip G

1. This patient presents to your family practice office feeling fatigued and complaining of off and on
angina relieved by rest. You run a strip and The CNP interprets strip H. as: Ventricular Paced—Failure to
Capture
2. What would you do Next? For hemodynamic instability/symptomatic chest pain, the patient would
need to be transcutaneous paced until the patient could be transferred to an inpatient facility with a
cardiology consult. A chest X-ray would be needed to view the lead wire as it may be displaced, battery
may be low, or there may be electrolyte disturbances causing a lack of capture in the pacemaker.

Strip H
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1. This patient comes to your family practice for a full physical. He has no complaints. The nurse runs a
strip for you, and you interpret this strip and document it as: Atrial Paced rate of 60.
2. Would you treat this patient? No, this rhythm does not need treated.

Strip I

References

American Heart Association. (2020). Algorithms. American Heart Association: CPR and First Aid Emergency
and Cardiovascular Care Algorithms. https://cpr.heart.org/en/resuscitation-science/cpr-and-ecc-
guidelines/algorithms.