Rhythm Identification Help

[BEorP]

I know that there is not too much to go on here, just lead II and not that great an image of a small segment of it. Any thoughts on what this is though?

Edited March 21, 2009 by BEorP

[FL_Medic]

I know that there is not too much to go on here, just lead II and not that great an image of a small segment of it. Any thoughts on what this is though?

- Fast HR 140-150

- Regular rhythm

- P waves present with low voltage (probably atrial/junctional)

- Shortened PR-interval (also indicative of atrial/junctional pacemaker)

- QS pattern (probably want a 12-lead so you can diagnose a BBB)

- ST-depression (Once again, ya need that 12-lead)

- Prolonged QT-interval

- Notched T waves (at first I thought that this was a p-wave at the end)

Dx - Since it's wide fast and regular, and there is no 12-lead available I would call it V-tach until proven otherwise. Of coarse I don't think it is V-tach. It's too slow, and I think those are p-waves just before the QRS complexes. You could call it SVT with the p- waves because they are not of SA node morphology.

Tx - I would just treat the patient's symptoms and acquire a 12-lead. If the 12-lead is negative for STEMI, and the patient is symptomatic. I would consider treating as SVT. On the other hand they may have a compensatory tachycardia. Is the patient febrile? Anemic?

[scott33]

Sinus tach, or another MAT

As above, treat the symptoms, and do a 12-lead for a closer look

Edited March 21, 2009 by scott33

[AnthonyM83]

I'd say SVT.

P waves look too similar to be MAT in my opinion.

FL_Medic, what does the PR interval length look like to you? I can't really see the smaller lines, but didn't seem that significantly shortened by eying it...

What's QS pattern? I thought that's what you called it when there were no R's...but there are.

Will a junctional pattern make that ST looking depression?

As far as the notched T-waves, if you don't think that's from a hidden p-wave, then where are the actual p-waves that you did see?

[BEorP]

Thanks for the replies. The patient was an 85 year old female complaining of chest tightness on and off since the previous day. She awoke with it that morning and her family convinced her to call 911 if I recall correctly. She had the same chest tightness from the previous day with slight shortness of breath. She did have a history of angina but described this as a worse feeling than her usual angina pain. Approximately 10 minutes before our arrival she took one spray of her nitro with no significant relief. Her BP was about 110/60 and I do not believe that the she was febrile. Unfortunately there is no 12 lead available.

Based on this information, what would your treatment for this patient be?

Would you be comfortable administering nitro to this patient without IV access? (neither my parter or I were certified to start IVs at the time of this call... let's leave that discussion for a different thread though)

Appreciate the feedback!

[FL_Medic]

I'd say SVT.

P waves look too similar to be MAT in my opinion.

FL_Medic, what does the PR interval length look like to you? I can't really see the smaller lines, but didn't seem that significantly shortened by eying it...

What's QS pattern? I thought that's what you called it when there were no R's...but there are.

Will a junctional pattern make that ST looking depression?

As far as the notched T-waves, if you don't think that's from a hidden p-wave, then where are the actual p-waves that you did see?

Oops... RS pattern. Look at the very beginning of the QRS segment. The first couple of complex show it the clearest.

[AZCEP]

You gents seem to be over thinking this. If you have clearly discernible P waves it is not VT or SVT, by definition. From this one lead the best you can say is that it is a regular tachycardia with an apparent origin from the atria.

I'd call it sinus tachycardia with a BBB, but withhold absolute interpretation until more leads are made available.

[FL_Medic]

They aren't CLEAR p-waves, and what does SVT stand for? I have always disagreed with the p-wave thing because p waves can indicate sinus, atria, or junctional origin which all fall under supraventricular. It's neither here nor there. Treat the patient and find out why it's fast.

Edited March 22, 2009 by FL_Medic

[scott33]

Yeah they are not the most obvious P-waves, but they are p-waves. The atypical morphology could either be as a result of depolarizing right at the terminal end of the unusual S-T segment, or perhaps something as simple as the patient having atrial hypertrophy - something you can pick up on one lead, and not inconsistent with her history.

I will stick with my first, first answer - sinus tach.

Treat her for her chief complaint.

[spenac]

Based on this information, what would your treatment for this patient be?

Would you be comfortable administering nitro to this patient without IV access? (neither my parter or I were certified to start IVs at the time of this call... let's leave that discussion for a different thread though)

Treat her chest pain per chest pain protocol. Oxygen, aspirin, nitro, morphine or other pain med if needed.

Nothing beyond aspirin and oxygen w/o an IV.