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FL_Medic

Strip Tease 6

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Stole these from a certain site. Thought they would be good for this. Answer will be revealed on 5/17/2009.

EKG1.jpg

EKG2-2.jpg

Let me know what you think.

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Wow. That's a good one. Do we have info on the pt? Vitals? SAMPLE?

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Looks like a bunch of electrical alternans or some whacky axis thing .... I'm going with cardiac tamponade.

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Wow. That's a good one. Do we have info on the pt? Vitals? SAMPLE?

Sorry I don't have any info on the patient. I stole this one from another site. I do have the answer however.

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Looks like a bunch of electrical alternans or some whacky axis thing .... I'm going with cardiac tamponade.

I wouldn't say "a bunch", maybe more than one, but the QRS amplitude is otherwise pretty consistant.

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Stole these from a certain site. Thought they would be good for this. Answer will be revealed on 5/17/2009.

EKG1.jpg

EKG2-2.jpg

Let me know what you think.

Sinus Brady/arrythmia, 1st degree AV block *just a shame that PJC going in the middle as it could be wenkebach with a perfectly time PJC*, some degree of axial deviation but again, brain isn't awake just yet.

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I agree with the sinus arrhythmia and the i can see a 1st being there. However the pri looks too long in a few places to be a 1st. We were told that after a certain point(which i can't remember because i was more focused on what was going to be on finals) it becomes something else(which i can't remember either). Is this that thing with the change in the interthoracic pressure with respirations? It's "regularly irregular" i noticed.

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:jump: ANSWER :jump:

Bifocal Atrial Couplets & Left Anterior Fascicular Block

ECG description:

-Sinus rhythm with varied rate: 75-130 bpm

-Premature Atrial Contractions (PAC) presenting in couplets

-Left Axis Deviation (LAD). Cardiac Axis is deviated leftwards and superiorly at approx. 90°

-Left Anterior Fascicular Block (LAFB) due to LAD, deep S in III, no sign of LVH or MI

-Low Voltage in Limb Leads

-Poor R Wave Progression (PRWP)

Atrial Couplets, PACs and P waves

After one sinus cycle, the rhythm is interrupted by a PAC (complex no. 3 from the left). The change in P wave axis and morhpology of this complex suggests ectopy. The P’ wave is inverted in leads II, III and aVF, suggesting that the ectopic impulse originates in the left atria, spreading in a retrograde fashion. Determining by the PR interval, which is 100 ms, the ectopic pacemaker is atrial and not junctional, and sits closer to the AV Node than the SA Node.

The PAC is immediately followed by a new PAC, creating an atrial couplet. This second PAC seems to originate from another focus, as there is a change in P’ wave axis and configuration. The PR interval of this PAC is 110ms, and the P’ waves are upright in the inferior leads, suggesting that it spreads inferiorly and towards the left. The second PAC is followed by two sinus cycles, which is then followed by another PAC couplet. The PACs in this couplet seem to originate from the same ectopic foci as in the first couplet, although there is a variation in coupling interval length.

Atrial couplets can be benign, but are less common in healthy hearts, and should increase suspicion towards onset of atrial fibrillation. Ultimately, one would prefer to print a longer rhythm strip at this point, to see the phenomenon over a longer time interval. Unfortunately this is not available for this particular case.

The Postextrasystolic Pause

With supraventricular premature impulses, the dominant automaticity focus (normally the SA Node, as in this case) is usually reset by the premature impulse. The supraventricular impulse usually activates the whole atria and thereby also the SA Node. The early activation of the SA Node interrupts the pacing function of the node, and causes a delay in impulse generation. The next impulse will then be slightly delayed, causing the following RR interval to be prolonged. This is called a noncompensatory pause. If the SA Node is not reset, then its pacing function will not be disturbed, and the following RR interval will be an exact multiple of the normal interval, resulting in a compensatory pause.

PACs usually present with non-compensatory pauses, as ectopic atrial impulses will usually activate the whole atria, including the SA Node, and thereby interrupting the sinus pacing activity. In this EKG, the pause after the first PAC is interrupted early by another ectopic impulse, so this pause cannot be determined. The second PAC however (complex no. 4 from the left) is followed by a postextrasystolic pause that is prolonged, but still not an exact multiple of the normal sinus cycle length. This is a non-compensatory pause, which tells us that the SA Node has been reset. This helps to establish and diagnose an atrial origin for the ectopic beats.

Courtesy of pqrst

Edited by FL_Medic

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