What's the rhythm?

[Camulos]

I'd also call that MAT. P wave morphology seems different from one to another, PRI and RRI are both variable, rate > 100. That certainly fits the criteria for MAT as far as I recall.

I definitely don't think it is AF as earlier stated as the P waves are very easily discernable.

It would be great to hear the three different answers from the ER Docs that were asked by the OP.

Stay safe,

Curse

[fiznat]

Thanks Doc, but why can't it be arrhythmia with PAC's. Take a look at the XII lead, there are clearly what appear to be round upright p-waves. I was under the impression that WAP and MAT all have different P-wave morphologies as well as varying PRI. The rhythms he showed us have Complexes that are regular, as well as some that are premature and late with varying p-wave morphologies.

I think the differing P wave morphology is most evident in the rhythm strip, which makes sense because you can only see 4 beats in each view on the 12 lead. You really need the longer strip to make sense of the varying PR interval and (what I agree are) varying morphologies.

I called MAT on this as well, although the docs all disagreed with me haha. The answers were:

1. A-fib (?? you tell me. He pointed at lead III in the rhythm and said he saw the fib. Meh.)

2. Sinus Arrhythmia (I agree with above that the varying PRI is a strike against this)

3. Accelerated Junctional Rhythm w/ retrograde P waves (no.)

I got the distinct impression that these docs didn't really care what the rhythm actually was. I understand that the patient was otherwise stable and precise identification of the rhythm isn't exactly critical, but I have to say I was a bit disappointed in the answers I got.

I also posted these strips in another forum I frequent (for docs and med students). They called MAT as well. Here's the link if you're interested: http://forums.studentdoctor.net/showthread.php?t=608265

[itxtme]

I find it difficult to see why this would ever be Afib, the doctor that thought it was based on lead II soley suprises me. Anything could be causing interfernce on that lead, and the lack of disorganiztion in any of the other leads points towards a dodgy sticky, poor contact or limb movement.

Like the above poster I will underline why I think it is MAT and not Afib or sinus arrythmia

Decernable P waves before QRS complexes (against afib)

Multiple amplitudes and morphologies of the P Waves [they look differnt] (against sinus arrythmia)

For sinus arrythmia I would expect similar [same] shaped P waves in front of each QRS, this is just not the case in the strip. Somebody is right and the rest of us are wrong; wheres a cardiologist when you need one - maybe I should just mentions Nazi's and forfit the debate (godwins law for those who are confusedO.

[Wraith]

Ok.....I'll give it a try. How about MAT with a hemodynamic reflex to respirations. Looks like there a few different morph's of P waves with althought minimal variation to the PRI. However minimal there is still variation. Looks like the rhythm speeds and slows with what could be a respiratory rate association. Normally I just lurk and read but thought I'd get in on this one. Be gentle.

[dlevy]

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

Looking at this my first response was that is was A-fib.

Now I don't study them as the Doc's like to.

Yet I also have been teaching ACLS for the past 13 years and have found that if you get 4th Doc to look at it they will probably call it something else. We as paramedic's don't read that much into these.

[FL_Medic]

Fiz posted this on SDS and it seemed that the replies mostly indicated/diagnosed MAT as well. I asked the expert here in electrocardiography and he stated that he felt this was MAT.

Let's talk about this though, how would you truly know what the rhythm is? Compare against some of the other suggestions in this post and describe how you would decide between all the choices. Is there another diagnostic tool besides an EKG? Maybe an echo?

[Camulos]

Apart from the ECG criteria I am unaware of any other test that would confirm or differentiate the diagnosis of MAT. There is a paucity of evidence regarding the clinical significance of MAT however what does exist tells us that it is a transient rhythm (usually) that is a secondary effect of a clinical syndrome. The most common culprits here are COPD, CHF, hypoxemia, PE and theophylline toxicity. Considering this, I guess pt history and present diagnosis may sometimes provide that differentiating factor. As the rhythm is a transient secondary phenomenon, the cornerstone of treatment is to treat the causative condition, which should normalise the rhythm.

I have personally never seen clinically significant MAT that required treatment in itself. I understand the drug of choice in this case is metoprolol however its use may be contraindicated in the setting of some of the main causes of MAT (COPD, CHF, hypoxemia) due to beta blocker induced bronchoconstriction. I have heard magnesium may have some role but I really don’t know much about this.

It would be great to hear others’ experience with this or indeed if there is a definitive test for MAT (apart from ECG).

Stay safe,

Curse

[EMS49393]

We as paramedic's don't read that much into these.

Speak for yourself. I am damn good at interpreting the 12-lead, and I find it to be a very important assessment tool (thanks, Bob). It can only be an appropriate assessment tool if you know what you are looking at.

Imagine if a paramedic "didn't read much into" the strip and called it V-Tach. Why run a 12-lead, after all, we don't read much it them. Meanwhile your patient is unstable due to this rhythm, you don't have amiodarone and you go ahead with some lidocaine. Congrats on your kill.

What is the point of having this technology to our advantage if we aren't able to use it to its fullest? Being a paramedic isn't an excuse to not push ourselves to learn as much about medicine as we can. In fact, it is the paramedic that does not advance their knowledge that keeps our profession behind.

[grems4305]

Could be tachy-lordie with junctional jesus's - lordie, lordie, lordie, jesus, lordie, jesus, lordie, lordie

[LyonN]

That is MAT, or A-fib they are the same thing if you look at the definitions. All paramedics need to be at the top of our game at rhythm recognition. The question is does it have a normal P wave? Is there a narrow QRS? If you answered yes to both those questions it is sinus in nature. In this case you didn’t. As far as the inferior QT segment changes no I would disagree with that too there is little change in lead II that is it. There needs to be changes in two or more congruent leads. That is not the case here. This is my first post so let me know if you agree.

Edited March 23, 2009 by LyonN