Dooger

Double 'P' waves?!?

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Dooger    3

We had a bit of a head scratcher last week I thought I would throw out for insight...

For the sake of this discussion (or at least until I can recall all the details :roll: ) we'll assume the patient was a post-syncopal, asymptomatic, normotensive and otherwise stable middle-aged female. Routine 3 lead ECG showed distinct, prominent dual 'P' waves of differing morphology immediately preceding each QRS complex, otherwise it was a normal ECG (no blocks, ectopic beats, rate changes or irregularities). Sorry, I don't have a graphic to post.

We were considerably puzzled by the dual 'P'waves with the absence of additional QRS complexes. Only logical explanation we could muster was some sort of genetic sinus anomaly.

Thoughts? Ideas?

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mobey    275

How far apart were the P-Waves?? What was the rate? Maybe a rapid Classic type 2, Maybe Flutter waves? It could be an Atrial focused ectopic with a 2:1 Block, Check out this article.

Do you have anymore specifics?

http://www.medscape.com/viewarticle/433023

Mobey

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medic001918    0

I agree that it's hard to speculate with what little information has been posted. My initial thoughts are an a-flutter with 2:1 conduction or a second degree type II (mobitz) block. Or quite possibly, maybe even a third degree heart block?

I'm curious without knowing too much about your system, but why are you doing cardiac monitoring if you don't know some of the basic rythems that can be determined by a three lead EKG? The flutters and heart blocks are common entry level cardiac rythems to determine and have been taught in every cardiology class I've ever taken? I'm not bashing here, just looking for the rationale.

Shane

NREMT-P

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JakeEMTP    54

Sounds like a 2nd degree block type II. There are always more P waves than ORS complexes. Although, you mention that the P waves are of different morphology. As you are aware, P waves are uniform in 2nd degree type II. I will have to monitor this thread. Hopefully you can provide some more information. :wink:

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Dooger    3
How far apart were the P-Waves?? What was the rate? Maybe a rapid Classic type 2, Maybe Flutter waves? It could be an Atrial focused ectopic with a 2:1 Block

Do you have anymore specifics?

Mobey

P-waves are uniform & tight against each other with 2 P's immediately preceding each QRS. They are distinct p-waves, definatley not flutter waves. On our arrival the patient's vital signs were all within normal limits, no known hx of SVT.

Interesting article, although there could be a possibility based on the article that she had been in a tachy arrythmia PTA, the P-waves in that particular instance seem to be buried in the previous T-waves which would be consistant with the block theory. These P's were together. We considered every type of block but because the P-waves were so close we had rule a block out. Because they were so distinct (no notching) P-mitrale was also ruled out.

I'm working again tomorrow and think I may have a copy of the ECG in my locker (ya, I collect strange things). I'll try to get it scanned and posted for ya ASAP.

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Dooger    3
I agree that it's hard to speculate with what little information has been posted. My initial thoughts are an a-flutter with 2:1 conduction or a second degree type II (mobitz) block. Or quite possibly, maybe even a third degree heart block?

I'm curious without knowing too much about your system, but why are you doing cardiac monitoring if you don't know some of the basic rythems that can be determined by a three lead EKG? The flutters and heart blocks are common entry level cardiac rythems to determine and have been taught in every cardiology class I've ever taken? I'm not bashing here, just looking for the rationale.

Shane

NREMT-P

Careful Shane, your making some pretty brash assumptions and are being quite offensive. Maybe inquiry would be prudent before making assumptions?

We are a larger (~20,000 calls/yr) urban ALS system, most of our basic EMT's are also trained (and reasonably proficient) in ECG interpretation, our medics teach ACLS to the doctors. Our organization is quite up to date and progressive when it comes to cardiology, so don't be a smart a**, we know what a block looks like!

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medic001918    0

Careful Shane, your making some pretty brash assumptions and are being quite offensive. Maybe inquiry would be prudent before making assumptions?

We are a larger (~20,000 calls/yr) urban ALS system, most of our basic EMT's are also trained (and reasonably proficient) in ECG interpretation, our medics teach ACLS to the doctors. Our organization is quite up to date and progressive when it comes to cardiology, so don't be a smart a**, we know what a block looks like!

It wasn't an assumption at all. In fact, if you read closely you would have noticed that the entire thing was phrased as two questions. And you'll also notice that I was not bashing either, I was just looking for the rationale. The initial post was rather vague in an attempt to aquire information. And based on what was posted it sounded very much like the basic heart blocks that have already been presented as possibilities. Make sure you look at the entire post before getting worked up and taking offense. They were questions...implying that I was looking for answers. If it were an attempt to bash you, they would have been statements.

For an example, you can look here: http://www.madsci.com/manu/ekg_hypr.htm under left atrial enlargement.

But since you've provided some more information to work with...let's see what we can come up with. Is it possibly a biphasic p-wave which would be indicative of atrial enlargement? There are biphasic p-waves that appear to be two p-waves side by side without breaking the isoelectric line.

Shane

NREMT-P

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Dooger    3
...why are you doing cardiac monitoring if you don't know some of the basic rythems that can be determined by a three lead EKG? The flutters and heart blocks are common entry level cardiac rythems to determine and have been taught in every cardiology class I've ever taken?

Shane

NREMT-P

Come on Shane, who wouldn't take offence? What you wrote is very condescending no matter how you want to "phrase" it - question or statement (that last "question" is just a statement with a question mark).

Just say sorry and be a little more considerate how you "phrase" your comments. And I'll promise not to call you a smart a**, fair enough?

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medic001918    0

No need to apologize for calling me a smart a**. I didn't take offense to it. I'm not familiar with the canadian system and their levels of training. So I wouldn't know what someone trained to your level is capable of identifying and what they're not with regard to cardiology. It was quite possible that the blocks are beyond the training and education that you had been given.

But in order to prevent this thread from falling apart over semantics, please accept my apology.

Shane

NREMT-P

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