Fun in EKG Rhythm Analysis

[crotchitymedic1986]

10 cardiologists would come up with 10 diagnosis', but I would call it third degree with conduction delay, regardless of what you call it, it is too slow and needs to be corrected immediately, so argueing over what it is really moot. What was the patients b/p supine and sitting ?

[mobey]

Now that I look at those with my good screen, I can see what looks like regular P waves.

Need a 12 lead, but looks to be 3rd Degree.

Treatment the same either way for me. We can debate Atropine in a 3rd Degree all day (and we have) but my previous Tx is what I will stand by.

[wrmedic82]

10 cardiologists would come up with 10 diagnosis', but I would call it third degree with conduction delay, regardless of what you call it, it is too slow and needs to be corrected immediately, so argueing over what it is really moot. What was the patients b/p supine and sitting ?

Unfortunately I cannot give you info on blood pressure or whether or not she had a positive tilt. This is due to me being in a monitoring center and not in the field at the moment. Dr was contacted immediately after the incident. The rhythm did speed up to 32-34 bpm. I would post that strip up but it would exceed the bandwidth.

[DwayneEMTP]

I would love to see that strip.

I'm curious how she began a regular rhythm at such a slow rate when it appears that the AV node is firing around 70+? Unless it's a ventricular rate of course, but didn't you say that she converted to a sinus rhythm? Hmmm...will have to read back.

And Crotchity, every friggin' time I try and be convinced that you're more than just a pain in the ass you say something like, "10 cardiologists, 10 answers..moot"...what bullshit! This isn't about pt care any more, this is about education. You aren't interested as no blacks are being abused in this thread, so you can leave it alone, but why are you so motivated to be negative? I can't figure you out man...

Dwayne

Now that I look at those with my good screen, I can see what looks like regular P waves.

Need a 12 lead, but looks to be 3rd Degree.

Treatment the same either way for me. We can debate Atropine in a 3rd Degree all day (and we have) but my previous Tx is what I will stand by.

I disagree with the third degree brother because a third degree is disassociation, yet in this case we have the absence of muscle activity in both hemispheres, right? If a third degree then we should have atrial involvement with each electrical impulse, yet we don't. I do agree that the rare beat that we do get is likely a ventricular escape beat.

Anyway, cardiology is not my strongest suit, in fact it's near the bottom, with all of my other suites..grin. No disrespect intended to your opinion of course.

Dwayne

[mobey]

I disagree with the third degree brother because a third degree is disassociation, yet in this case we have the absence of muscle activity in both hemispheres, right? If a third degree then we should have atrial involvement with each electrical impulse, yet we don't. I do agree that the rare beat that we do get is likely a ventricular escape beat.

Dwayne

Oh good, we get to disagree!

Firstly... you knew I was going to pick up on the bolded words above, as with ECG's we are not looking at "muscle activity" at all, just electrical. *One for mobey*

Anywhoo.

I disagree with your assessment of lack of atrial depolarization. Although hard to see, there are definatly P waves present, and they are regular.

The Ventricular beats are tricky though.... IF they are indeed regular... even at 20BPM this will be called a 3rd Degree. Unfortunatly we cannot determine that since the strips are so short.

However, if the QRS are irregular, it would be fair to label this maybe "Ventricular standstill with occasional PVC's or Agonal ventricular beats". Gotta say though... That is quite a stretch.

So I think it really undeterminable by these 3 strips alone, however, I will anecdotaly say, I have a stronger belief that people can go in and out of a 3rd degree way more commonly than a ventricular standstill. I suppose because I have experience with multiple people who have self converted 3rd degrees, and a Ventricular standstill seems like a more lethal rythm from a really sick heart.

Dunno

[wrmedic82]

Here is a link to my facebook page where the 4th strip is.

http://www.facebook.com/photo.php?fbid=477983987770&set=a.478001837770.261723.514357770&pid=5828643&id=514357770

[fiznat]

Facebook link is a 3rd degree. Posted ECG has gotta be ventricular standstill. I see some activity which is likely atrial (p waves), but nothing happening below the AV node other than that one beat. Atrial activity without ventricular response or escape = ventricular standstill.

We shouldn't be discussing treatment of this patient at all, as no assessment is possible. Still, I think it's probably safe to say that this patient is sick, sick, sick.

Cool strip, thanks for sharing!

[wrmedic82]

The answer to all of the above is Third Degree AV Block with IVCD. In the first strip as some have states there are P waves w/o a corresponding QRS. In short the P waves are doing their dizzle and the QRS's are doing their dizzle. But they aint working together fo shizzle. The first three strips was the actual onset of the block. As stated earlier, the original rhythm was First degree with IVCD. The IVCD explains the wide QRS. Thats why they are not PVC's but normal beats. Compare the beats on the 18 second strip to that of the picture on facebook. They are identical! Stay tuned I have another interesting patient coming soon.

Edited December 21, 2010 by wrmedic82

[mobey]

We shouldn't be discussing treatment of this patient at all, as no assessment is possible.

Anytime we can discuss treatment it can only be good.

I don't need a assessment to discuss treatment modalities on a cardiac issue. I am not saying how I would treat this individual, I am stating how 3rd degree blocks are treated.

To be fair, we have no access to assess any patients online, that is why we talk in hypothetics.

[DwayneEMTP]

...firstly... you knew I was going to pick up on the bolded words above, as with ECG's we are not looking at "muscle activity" at all, just electrical. *One for mobey*

Yeah, what a bonehead statement that was! I was kind of trying to be clever as the P waves look biphasic and the amplitude is so low that I was trying to make something out of that. Yikes. Ive only run one 12 lead in the last 4 months and it seems that already I've forgotten the little that I actually knew before! Remote medicine can be murder on skills.

I really really hate it when I step on my weenie and then can't get back to my computer to defend myself! :-)

This was an awesome discussion, and as you can see, one that I was dearly needing.

Dwayne