EKG no one can figure out.

[Aidey]

Even with the P-wave superimposed on top, the ST-segment should be slightly depressed. If you look very carefully the J-point is elevated about a isoelectric line width above the expected position which is significant because of the very small amplitude of the QRS (rule of proportionality). In the first cardiac cycle the ST-segment appears to be slightly up-sloping. That could be artifactual, but taken together with the little Q-wave in lead III and the unusual (possibly reciprocal) ST-depression in lead aVL it's something to keep an eye on. That's all I'm saying.

On the blown up version in lead III the J point is below the line preceding the QRS complex, and exactly level with that small positive deflection immediately before the Q wave.

Since she has a LBBB isn't it expected that the T wave would have a negative deflection in aVL?

P's walk out. Complexes walk out. Rate's slow enough, and complexes wide enough. I'm calling it 3° AVB.

The PRI is also variable. I was divided between 2nd degree type II and 3rd, but now I'm much more inclined to call it a very high 3rd degree block.

Tom, I have to disagree with your pacemaker statement. Although the LP 12 (which this appears to be) does not show pacer spikes on the screen, it shows them on the print out both on the strip and by printing arrows underneath the paced beats. It also notes it in the interpretation. Speaking of which, this is a good argument against relying on them.

I'd call that a 2nd degree Type II block. I wouldn't pay inordinate attention to the RBBB interpretation either. The biphasic P wave always makes me think that the patient has COPD.

Other than that, absent an acute cardiac problem that needed treatment immediately, I'd be inclined to treat the patients original complaint.

TOTWTYTR - What's up my brotha! Just for the record the pacer detector needs to be turned on for little box arrows to appear. In my experience most LP12s default to them being turned off (but of course I have no idea how this one is configured). It's the timing cycles that give the answer away in this case. The odds of a patient's intrinsic rhythm mimicking a pacemaker's behavior at exactly 1000 ms seem long to me.

I don't know why it was saying RBBB, the pt had a history of a LBBB, and the 12 lead reflects that. It was a LP 15, and it is configured to show the pacer arrows. Which is moot in this case since the patient did not have a pacemaker.

I have noticed however that if the patient's pacemaker was implanted within the last 2-3 years and there is much artifact at all the LP 15s are not very good at picking up spikes consistently. Some of the new ones are very hard to see.

 

[Too Old To Work]

It was a LP 15, and yes it is configured to show the little arrows. Which is moot in this case since the patient did not have a pacemaker.

I didn't know they had to be configured to point out pacer spikes as I've never seen one that didn't do it. Nice to see that the LP15 print out is identical to the LP12. Now, if I can get my employer to buy them, but I digress.

Despite Tom's doubts, I'm sticking with my interpretation.

PMHx: HTN, hyperlipidema, diabetes, A-Fib, LBBB, COPD, Asthma, CHF. Kidney transplant 10 years ago, one failed transplant before that. Reports that all recent labs have shown her kidney function is fine. She is scheduled for a pacemaker in a week because of a "slow heart rate". Pt reports that over the last month she has had several episodes of her heart rate being as slow as 36 bpm. She does not know the specific diagnosis. None of the potential dxs sounded familiar to her.

Given all of this and her chief complaint I would, as I said earlier, concentrate on treating her dyspnea and not worry about a funky ECG too much.

It's more than a bit aggravating that patients sometimes insist on doing things that the text books tell us they shouldn't be able to do. Especially when it comes to their hearts. <_<

 

[Aidey]

I didn't know that either, but since they show up, it must have that setting turned on. We have both 12s and 15s, and I must say, the 15s are nice. Even though the computer interpretation is still wrong, it doesn't seem as wrong, as often. They also have less artifact, and while I haven't timed it I think they analyze and print faster.

Between the MDs and my coworkers that is where the debate has fallen, 2nd degree type II or 3rd degree. I'm going with 3rd becuase the PRI is not constant. Something tells me that even if I started polling cardiologists I wouldn't get a concrete answer.

The only thing I did about the funky EKG was drive faster. Since I wasn't sure what it was, I wasn't sure what it was going to do next, and I didn't want to have to find out. Because of construction and rush hour a drive that normally takes 12-15 minutes no code was estimated to take 35, which was a little longer than I wanted to risk.

 

[Too Old To Work]

I didn't know that either, but since they show up, it must have that setting turned on. We have both 12s and 15s, and I must say, the 15s are nice. Even though the computer interpretation is still wrong, it doesn't seem as wrong, as often. They also have less artifact, and while I haven't timed it I think they analyze and print faster.

Not as wrong as often is a vast improvement! :rofl: That aside, from what I've seen the LP15 is a nice piece of gear.

Between the MDs and my coworkers that is where the debate has fallen, 2nd degree type II or 3rd degree. I'm going with 3rd becuase the PRI is not constant. Something tells me that even if I started polling cardiologists I wouldn't get a concrete answer.

You might be right, but then again I might be right. In this case, I think the issue is moot. She had plenty of BP, so I'd worry about treating her dyspnea and leave the cardiac stuff for the hospital.

The only thing I did about the funky EKG was drive faster. Since I wasn't sure what it was, I wasn't sure what it was going to do next, and I didn't want to have to find out. Because of construction and rush hour a drive that normally takes 12-15 minutes no code was estimated to take 35, which was a little longer than I wanted to risk.

The lady is, to put it nicely, a train wreck.

 

[Dutch-EMT]

AV Block type II 2:1.
It goes like: P - QRST - P - Pause - P - QRST - P - Pauze - etc.

When i see the deep S in V1, i think there's a LBBB. That makes the complex wider.
Ventricular respons is 60 times a minut, while the P top shows at a rate of the double of it. It is also a regular rhytm.

This seems a patiënt for a pacemaker.

 

[Aidey]

I know I'm bumping my own ancient thread, but I finally was able to get a conclusive diagnosis for this patient, from the pts cardiologist, through my MD.

It is a 3rd degree AV block.