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10 Introducing the Ventricular Rhythms Understanding EKGs: A Practical Approach, Third Edition Brenda M. Beasley Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Introducing the Ventricular Rhythms • Objectives – Discuss the origin of the ventricular rhythms – Review specific components of the electrical conduction system of the heart – Identify premature ventricular contractions, including EKG characteristics – Identify idioventricular rhythm, including EKG characteristics – Differentiate idioventricular rhythm and accelerated idioventricular rhythm Understanding EKGs: A Practical Approach, Third Edition Brenda M. Beasley Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Introducing the Ventricular Rhythms • Objectives (continued) – Identify ventricular tachycardia, including EKG characteristics – Identify ventricular fibrillation, including EKG characteristics – Identify ventricular asystole, including EKG characteristics – Discuss pulseless electrical activity – Discuss the clinical significance of the ventricular rhythms Understanding EKGs: A Practical Approach, Third Edition Brenda M. Beasley Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Origin of the Ventricular Rhythms • The rhythms are classified according to the heart structure in which they begin, or their site of origin • The sinoatrial (SA) node or the AV junctional tissues fails to generate an impulse • If this failure develops, the VENTRICLES will assume the role of pacing the heart Understanding EKGs: A Practical Approach, Third Edition Brenda M. Beasley Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Origin of the Ventricular Rhythms • Rhythms that are initiated in the area of the ventricular are called ventricular rhythms • Ventricular rhythms are the least efficient of the heart’s pacemakers; you should recall that patient assessment is the most important indicator of clinical significance Understanding EKGs: A Practical Approach, Third Edition Brenda M. Beasley Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Components of Electrical Conduction System of the Heart Understanding EKGs: A Practical Approach, Third Edition Brenda M. Beasley Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Origin of the Ventricular Rhythms • Impulses that are ventricular in origin begin in the lower ventricular musculature • Impulse may travel in retrograde (backward) direction to depolarize the atria • Impulse may travel antegrade (forward) to depolarize the ventricles • Either way, the normal conduction pathway is bypassed Understanding EKGs: A Practical Approach, Third Edition Brenda M. Beasley Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Understanding EKGs: A Practical Approach, Third Edition Brenda M. Beasley Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Origin of the Ventricular Rhythms • Due to bypass, ventricular rhythms will display QRS complexes that are wide (greater than or equal to 0.12 seconds) and bizarre in appearance • Absence of P waves because they are hidden or buried in QRS complex • Remember that QRS complexes of supraventricular rhythms are commonly less than 0.12 seconds in duration Understanding EKGs: A Practical Approach, Third Edition Brenda M. Beasley Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Premature Ventricular Complexes (Contractions) (PVC) • Individual complexes rather than an actual rhythm • Single ectopic (out-of-place) complex that occurs earlier then the next expected complex • Arises from an irritable site in the ventricles • The significance of PVCs is based entirely upon the patient’s clinical condition Understanding EKGs: A Practical Approach, Third Edition Brenda M. Beasley Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Premature Complexes Premature Ventricular Ventricular Complexes (Contractions) (Contractions) (PVC) (PVC) • The underlying cadence of SA node is not interrupted by a PVC nor is SA node depolarized • PVC is usually followed by a compensatory pause • Presence of compensatory pause, coupled with wide, bizarre, and premature QRS complex’s are highly suggestive indicators of PVCs Understanding EKGs: A Practical Approach, Third Edition Brenda M. Beasley Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Compensatory Pause Understanding EKGs: A Practical Approach, Third Edition Brenda M. Beasley Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Premature Premature Ventricular Ventricular Complexes Complexes (Contractions) (Contractions) (PVC) (PVC) • PVC may fall between two sinus beats without interfering with the rhythm • Referred to as an interpolated beat • PVCs appear in many different patterns and shapes • The morphology, or shape, of the PVC is based on the site of origin of the ectopic focus Understanding EKGs: A Practical Approach, Third Edition Brenda M. Beasley Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. PVC Patterns of Occurrence Understanding EKGs: A Practical Approach, Third Edition Brenda M. Beasley Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Premature Ventricular Complexes Understanding EKGs: A Practical Approach, Third Edition Brenda M. Beasley Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Premature Ventricular Complexes Unifocal Understanding EKGs: A Practical Approach, Third Edition Brenda M. Beasley Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Premature Ventricular Complexes Multifocal Understanding EKGs: A Practical Approach, Third Edition Brenda M. Beasley Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Understanding EKGs: A Practical Approach, Third Edition Brenda M. Beasley Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Premature Ventricular Contractions (Complexes) OR PVCs • PVCs often indicate myocardial irritability; multifocal PVCs are more serious then unifocal PVCs • Salvos – Runs of ventricular tachycardia • Any indication of increased myocardial irritability dictates that the patient be carefully evaluated and managed Understanding EKGs: A Practical Approach, Third Edition Brenda M. Beasley Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Ventricular Bigeminy and Couplet PVCs Understanding EKGs: A Practical Approach, Third Edition Brenda M. Beasley Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Understanding EKGs: A Practical Approach, Third Edition Brenda M. Beasley Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Ventricular Bigeminy Understanding EKGs: A Practical Approach, Third Edition Brenda M. Beasley Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Ventricular Trigeminy Understanding EKGs: A Practical Approach, Third Edition Brenda M. Beasley Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Understanding EKGs: A Practical Approach, Third Edition Brenda M. Beasley Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Understanding EKGs: A Practical Approach, Third Edition Brenda M. Beasley Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Understanding EKGs: A Practical Approach, Third Edition Brenda M. Beasley Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. R on T Understanding EKGs: A Practical Approach, Third Edition Brenda M. Beasley Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Understanding EKGs: A Practical Approach, Third Edition Brenda M. Beasley Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Idioventricular Rhythms • Also termed ventricular escape rhythms, considered a last-ditch effort of the ventricles to try to prevent cardiac standstill • Means SA node and AV node have failed • Rate usually less than 40 bpm, and cardiac output is usually compromised Understanding EKGs: A Practical Approach, Third Edition Brenda M. Beasley Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Agonal Rhythm • Agonal rhythm is when the idioventricular rhythm falls below 20 bpm • Frequently may be seen as the lastordered semblance of a heart rhythm when either resuscitation is unsuccessful or after successful defibrillation Understanding EKGs: A Practical Approach, Third Edition Brenda M. Beasley Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Idioventricular Rhythms • Causes include extensive myocardial damage, secondary to acute myocardial infarction, or failure of higher pacemakers • Is considered a lethal rhythm and treatment must be immediate and aggressive Understanding EKGs: A Practical Approach, Third Edition Brenda M. Beasley Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Idioventricular Rhythms Understanding EKGs: A Practical Approach, Third Edition Brenda M. Beasley Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Accelerated Idioventricular Rhythm • May occur when the rate of the ectopic pacemaker exceeds 40 bpm • Commonly accepted rate is 40-100 bpm • There are no P waves or PR intervals noted Understanding EKGs: A Practical Approach, Third Edition Brenda M. Beasley Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Accelerated Idioventricular Rhythm Understanding EKGs: A Practical Approach, Third Edition Brenda M. Beasley Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Understanding EKGs: A Practical Approach, Third Edition Brenda M. Beasley Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Accelerated Idioventricular Rhythm • May occur in conjunction with myocardial ischemia • Can be mistaken for ventricular tachycardia • Imperative that you remember to always assess and treat the patient, rather than the monitor or EKG strip Understanding EKGs: A Practical Approach, Third Edition Brenda M. Beasley Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Ventricular Tachycardia Rhythms • This rhythm is one in which three or more PVCs arise in sequence at a rate greater than 100 bpm • This rhythm commonly overrides the normal pacemaker of the heart • Often occurs rapidly and is initiated by a PVC or by PVCs occurring in rapid succession Understanding EKGs: A Practical Approach, Third Edition Brenda M. Beasley Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Ventricular Tachycardia Rhythms • If rhythm is sustained, patient’s clinical condition may rapidly deteriorate • A sustained rhythm is one that lasts for more than 30 seconds • If lasts for less than 30 seconds, it is a nonsustained rhythm,or simply a run of V tach Understanding EKGs: A Practical Approach, Third Edition Brenda M. Beasley Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Ventricular Tachycardia Understanding EKGs: A Practical Approach, Third Edition Brenda M. Beasley Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Ventricular Tachycardia • Is classified (based on assessment of the patient’s clinical presentation) as either pulseless V tach or V tach with a pulse • Immediate treatment is based on the presence or absence of a palpable pulse • Pulseless V tach – Immediate defibrillation Understanding EKGs: A Practical Approach, Third Edition Brenda M. Beasley Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Ventricular Tachycardia • Treatment of V tach with a pulse is based on patient’s clinical picture – Hemodynamically unstable (Low blood pressure, shortness of breath, etc.) Immediate cardioversion is considered – Hemodynamically stable ( Normal blood pressure, absence of chest pain, and no notable change in mental status ) Drug intervention is appropriate Understanding EKGs: A Practical Approach, Third Edition Brenda M. Beasley Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Ventricular Tachycardia • Causes may include – Myocardial ischemia, hypoxia, electrolyte imbalances, increased anxiety or physical exertion, and underlying heart disease Understanding EKGs: A Practical Approach, Third Edition Brenda M. Beasley Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Ventricular Tachycardia Rhythm Understanding EKGs: A Practical Approach, Third Edition Brenda M. Beasley Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Torsades De Pointes • Similar to ventricular tachycardia • Morphology of QRS complexes shows variations in width and shape • Resembles a turning about or twisting motion along base line • May result from – Hypokalemia, hypomagnesemia, tricyclic antidepressant drug overdose, use of antidysrhythmic drugs, or combination of these Understanding EKGs: A Practical Approach, Third Edition Brenda M. Beasley Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Torsades De Pointes Understanding EKGs: A Practical Approach, Third Edition Brenda M. Beasley Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Torsades De Pointes • Finding and treating the underlying cause of the rhythm is essential • Magnesium is the pharmacologic treatment of choice • Key to recognizing torsades is the variation of QRS morphology, or shape Understanding EKGs: A Practical Approach, Third Edition Brenda M. Beasley Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Ventricular Fibrillation • Is a fatal dysrhythmia • Is the most frequent initial rhythm occurrence in sudden cardiac arrest • Tends to occur in the initial hours following an acute myocardial infarction • Occurs as a result of multiple weak ectopic foci in the ventricles Understanding EKGs: A Practical Approach, Third Edition Brenda M. Beasley Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Ventricular Fibrillation • Myocardial cells appear to quiver rather than depolarize normally • No coordinated atrial or ventricular contraction, and no palpable pulse • Electrical impulses initiated by multiple ventricular sites; impulses are not transmitted through normal conduction pathway Understanding EKGs: A Practical Approach, Third Edition Brenda M. Beasley Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Ventricular Fibrillation • Waveforms appear as disorganized, rapid, irregular waves whose morphology varies vastly • No well-organized QRS complexes • Death will occur if immediate treatment is not established Understanding EKGs: A Practical Approach, Third Edition Brenda M. Beasley Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Ventricular Fibrillation • Classified as either – Fine ventricular fibrillation Ventricular fibrillation waves less than 3 mm of amplitude – Coarse ventricular fibrillation Ventricular fibrillation waves with amplitudes greater than 3 mm – Course fib is generally more irregular than fine fib Understanding EKGs: A Practical Approach, Third Edition Brenda M. Beasley Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Ventricular Fibrillation • Patient assessment is critical in that artifact, or loose leads can resemble ventricular fibrillation • Treat the patient… not the monitor • Causes include – Acute MI, myocardial ischemia, drug toxicity or overdose, hypoxia, and other causes Understanding EKGs: A Practical Approach, Third Edition Brenda M. Beasley Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Ventricular Fibrillation Understanding EKGs: A Practical Approach, Third Edition Brenda M. Beasley Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Ventricular Fibrillation (Fine) Understanding EKGs: A Practical Approach, Third Edition Brenda M. Beasley Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Ventricular Fibrillation (Coarse) Understanding EKGs: A Practical Approach, Third Edition Brenda M. Beasley Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Ventricular Asystole • The absence of all ventricular activity • Also called cardiac standstill or asystole • Asystole is represented by a flat line, and is the absence of all cardiac electrical activity Understanding EKGs: A Practical Approach, Third Edition Brenda M. Beasley Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Ventricular Asystole • It may be difficult to distinguish asystole from fine VF; you must always check two different leads to definitively identify asystole • Often follows unsuccessful resuscitation attempts • May be caused by – Massive MI, cardiac trauma, ventricular aneurysm, and complete heart blocks Understanding EKGs: A Practical Approach, Third Edition Brenda M. Beasley Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Ventricular Asystole Understanding EKGs: A Practical Approach, Third Edition Brenda M. Beasley Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Ventricular Asystole (Cardiac Standstill, Asystole) Understanding EKGs: A Practical Approach, Third Edition Brenda M. Beasley Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Understanding EKGs: A Practical Approach, Third Edition Brenda M. Beasley Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Pulseless Electrical Activity • The absence of a palpable pulse and myocardial muscle activity with presence of organized electrical activity on the cardiac monitor • Represents a clinical condition, the patient is clinically dead despite some type of organized rhythm on monitor Understanding EKGs: A Practical Approach, Third Edition Brenda M. Beasley Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Pulseless Electrical Activity • Formerly termed electromechanical dissociation, or EMD • Causes include – Profound hypovolemia, massive myocardial damage, ventricular rupture, pulmonary embolism, acidosis, cardiac tamponade, hypothermia, hyperthermia, drug overdose, hypokalemia, hyperkalemia, or tension pneumothorax Understanding EKGs: A Practical Approach, Third Edition Brenda M. Beasley Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Clinical Significance of Ventricular Dysrhythmias • Premature ventricular complexes – Little or no significance in patient’s without history of heart disease – May even relate that their caffeine or stress have increased the “palpitations” – Cardiac output may be compromised if PVCs are frequent – Administration of oxygen may abate the PVCs Understanding EKGs: A Practical Approach, Third Edition Brenda M. Beasley Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Idioventricular Rhythm • Majority are symptomatic • Due to decreased heart rate, may develop decreased cardiac output, weakness, dizziness, hypotension, and alterations in mental status • A thorough patient assessment is conducted to determine whether rhythm is perfusing Understanding EKGs: A Practical Approach, Third Edition Brenda M. Beasley Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Clinical Significance of Ventricular Tachycardia • May be perfusing (producing a palpable pulse) or nonperfusing (producing no palpable pulse) • Due to rapid heart rate, ventricles do not have time to empty and refill = cardiac output compromised • Treatment is based on the absence or presence of a palpable pulse as well as the patient’s clinical picture Understanding EKGs: A Practical Approach, Third Edition Brenda M. Beasley Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Clinical Significance of Ventricular Dysrhythmias • If V tach is perfusing and stable – Treatment consists of oxygen administration, IV lifeline, and pharmacologic intervention • If V tach patient becomes clinically unstable (as evidenced by hypotension, SOB, and CP) – Synchronized cardioversion is indicated Understanding EKGs: A Practical Approach, Third Edition Brenda M. Beasley Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Clinical Significance of Ventricular Fibrillation • There is no cardiac output, no perfusion – If not treated immediately, patient will not sustain life • The presence of fine V fib – Indicates rhythm has been present for extended period of time Understanding EKGs: A Practical Approach, Third Edition Brenda M. Beasley Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Clinical Significance of Ventricular Fibrillation • Treatment includes – CPR, defibrillation (360 J, one shock using monophasic or equivalent biphasic wave forms), airway control, IV lifeline, and drug intervention Understanding EKGs: A Practical Approach, Third Edition Brenda M. Beasley Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Clinical Significance of Asystole • Signals a complete termination of ventricular activity • Check in two leads to rule out the presence of fine V fib • Treatment includes – CPR, IV lifelines, endotracheal intubation, and pharmacologic intervention Understanding EKGs: A Practical Approach, Third Edition Brenda M. Beasley Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Chapter 10 Review Strips Understanding EKGs: A Practical Approach, Third Edition Brenda M. Beasley Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Review ChapterStrips 10 Review Chapter Strips 10 Understanding EKGs: A Practical Approach, Third Edition Brenda M. Beasley Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Review ChapterStrips 10 Review Chapter Strips 10 Understanding EKGs: A Practical Approach, Third Edition Brenda M. Beasley Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Chapter 10 Review Strips Understanding EKGs: A Practical Approach, Third Edition Brenda M. Beasley Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Chapter 10 Review Strips Understanding EKGs: A Practical Approach, Third Edition Brenda M. Beasley Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Chapter 10 Review Strips Understanding EKGs: A Practical Approach, Third Edition Brenda M. Beasley Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Chapter 10 Review Strips Understanding EKGs: A Practical Approach, Third Edition Brenda M. Beasley Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Chapter 10 Review Strips Understanding EKGs: A Practical Approach, Third Edition Brenda M. Beasley Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Chapter 10 Review Strips Understanding EKGs: A Practical Approach, Third Edition Brenda M. Beasley Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Chapter 10 Review Strips Understanding EKGs: A Practical Approach, Third Edition Brenda M. Beasley Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Chapter 10 Review Strips Understanding EKGs: A Practical Approach, Third Edition Brenda M. Beasley Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Chapter 10 Review Strips Understanding EKGs: A Practical Approach, Third Edition Brenda M. Beasley Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Chapter 10 Review Strips Understanding EKGs: A Practical Approach, Third Edition Brenda M. Beasley Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Chapter 10 Review Strips Understanding EKGs: A Practical Approach, Third Edition Brenda M. Beasley Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.
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