What's the rhythm?

[fiznat]

Alright folks. I showed this rhythm to 3 separate ER docs and got 3 different answers. Let's see what EMT City thinks...

Here's links to higher res versions: 3 lead 12 lead

[scott33]

Looks like MAT

[p3medic]

I agree with Scott.

[fiznat]

Can you guys explain your reasoning? I'm not saying I agree or disagree with you, but if you post the "why" as well it might help stimulate some discussion.

[EMS49393]

On first look, I called it a fast wandering atrial pacemaker which essentially is MAT, so I agree with the above.

Thanks for sharing it, I don't get to see that very often.

[spenac]

Well the strip interpetation is wrong as there are definite P-waves, though multi-focal, which eliminates A-Fib. Rate is irregular.

Almost looks like an irritable junctional foci is firing as p wave is inverted, but its not the more I look, then you are getting a pause as heart resets then you get back to atrial rhythm.

QRS is normal. Axis is normal.

Almost leaning towrds a Type 2 Wenkebach as lead II appears to have a widening pri then drops a beat.

There is that confusing.

[scott33]

Can you guys explain your reasoning? I'm not saying I agree or disagree with you, but if you post the "why" as well it might help stimulate some discussion.

An irregular rhythm >100 with some noticable p-waves and other morphologies that resemble p-waves. Narrow QRS, and a p-wave, or p-wave type shape before every QRS.

Using the above we can rule out all ventricular, rhythms and afib. Could it be a sinus arrythmia with PJCs or PAC's? perhaps, but the fact that you can clearly see variable different forms of p-waves and the associated irregularity of the rhythm as a whole, would lead me to think MAT before any other rhythm.

The origin of impulse is in and around the sinus node, with some foci being nearer the AV junction (shorter PRI) and some being further away (longer PRI and those noticable retrograde-antegrade P-waves).

Here is another confirmed one for comparison

http://www.emedu.org/ecg/images/ans/2mat_1.jpg

Sticking with my first choice

[nypamedic43]

It looks like a wandering pacemaker to me with maybe an occasional PJC. It's irregular with multifocal p-waves and some beats with no p-waves ( which is why I am thinking a junctional beat) but I could be wrong, even with the high res view it's difficult to see some of the p-waves. Thanks for sharing

[itxtme]

[AnthonyM83]

The occasional inverted p waves could still be MAT if the foci is low in the atrium and fires in upward direction first, correct? I'm blanking on the term.