# PAC or PVC?



## Shishkabob (Jul 7, 2009)

13yo syncopal episode, strip taken 5 minutes after.

Medic partner said it was a PAC, after quizzing me on it for a few minutes.   Looks like a PVC in 3 to me, but then again I'm still learning.












EDIT-- 30sec strip total, I can take more pics of it if required.


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## DrankTheKoolaid (Jul 7, 2009)

*re*

pvc, note the wide complex's


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## Ridryder911 (Jul 7, 2009)

Your partner better get the books out! I hope they are not treating cardiac patients. Basic EKG 101: PVC wide QRS, compensatory pause afterwards, abnormal T wave from the normal set pacer. 

Now I'm scared...

R/r 911


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## MSDeltaFlt (Jul 7, 2009)

I will neither confirm nor deny what it is until I see a 12 Lead.  Lead I seems to show a possible P wave before the complex, but it's not very good quality.  That coupled with the other ectopic focused beat with a an obvious P wave earlier in the strip, then there is a chance it is just an abarrant conduction.  Again, neither confirmed nor denied without a 12 Lead ECG.


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## Ridryder911 (Jul 7, 2009)

MSDeltaFlt said:


> I will neither confirm nor deny what it is until I see a 12 Lead.  Lead I seems to show a possible P wave before the complex, but it's not very good quality.  That coupled with the other ectopic focused beat with a an obvious P wave earlier in the strip, then there is a chance it is just an abarrant conduction.  Again, neither confirmed nor denied without a 12 Lead ECG.



PAC's usually does not have compensatory pause as well as such as a wide QRS. Abberant PAC in set pattern as well is not the usual. I am surprised that you would request a 12 to determine a PVC or not...

R/r 911


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## MSDeltaFlt (Jul 7, 2009)

Because, my friend, you never say never.  You never say always.


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## firecoins (Jul 7, 2009)

MSDeltaFlt said:


> Because, my friend, you never say never.  You never say always.



Is that always the rule?  :sad:


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## medic3416 (Jul 7, 2009)

I agree, based on what you presented they are most likely PVC’s. And I also agree that a 12 lead would be warranted. A history of syncope and PVC’s on initial limb leads = 12 lead for further investigation.  Especially if all else were WNL such as RR, SPO2, BP, BG, PERRL no trauma suspected ect. 

 Remember that limb leads are only useful for monitoring cardiac trends and to determine rate, most rhythms and rhythm regularity. Anything else needs a 12 lead including BBB’s, nature of ectopy, ischemia, infarction, electrolyte disturbances, and conduction irregularities and so on.


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## Ridryder911 (Jul 7, 2009)

MSDeltaFlt said:


> Because, my friend, you never say never.  You never say always.



Very true, but my point to the noobies, is a 12 lead should routinely be performed as in all cases, but I would not be concern to gather another one just because I did see ectopic beats. Not judging you.. by far. 

As well, many are no longer taught on the differentiation of left sided vs. right sided PVC's or to check to see if they are perfusing or not. 

R/r 911


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## medic3416 (Jul 7, 2009)

Ridryder911 said:


> _As well, many are no longer taught on the differentiation of left sided vs. right sided PVC's or to check to see if they are perfusing or not. _
> 
> R/r 911



   UHmm, that’s scary. I know ACLS teaches the importance of perfusing  vs non-perfusing PVC's and hopefully everyone is being taught PVC origin in cardiology as well as right precordial and posterior 12-leads.


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## terrible one (Jul 7, 2009)

Ridryder911 said:


> As well, many are no longer taught on the differentiation of left sided vs. right sided PVC's or to check to see if they are perfusing or not.
> 
> R/r 911





medic3416 said:


> hopefully everyone is being taught PVC origin in cardiology as well as right precordial and posterior 12-leads.



Sorry but I never was taught the difference between R and L sided PVCs. Care to enlighten me? 
thanks


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## MendoEMT (Jul 7, 2009)

There appears to be quite a bit of baseline artifact so I'm not sure that there _is_ a P wave before the complex in Lead I, but I won't rule it out. After both PVCs and PACs there is typically a pause, compensatory or otherwise...  I think that the wide complex though should be a dead giveaway for a PVC though.


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## usafmedic45 (Jul 7, 2009)

> I think that the wide complex though should be a dead giveaway for a PVC though.



Not at all. It could well be a PAC with aberrent (abnormal) conduction. You can technically have PSVT with aberrant conduction that looks for all the world like ventricular tachycardia.  Just because it is wide, does not mean it's ventricular in origin.


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## usafmedic45 (Jul 7, 2009)

MSDeltaFlt said:


> I will neither confirm nor deny what it is until I see a 12 Lead.  Lead I seems to show a possible P wave before the complex, but it's not very good quality.  That coupled with the other ectopic focused beat with a an obvious P wave earlier in the strip, then there is a chance it is just an abarrant conduction.  Again, neither confirmed nor denied without a 12 Lead ECG.


+1.  There is not enough information of sufficient quality to render a judgement.


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## Shishkabob (Jul 7, 2009)

Sadly no 12 lead was available... was using LifePak 10's with only 3 leads.


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## ResTech (Jul 7, 2009)

What are some possible causes of PVC's in a 13 y/o with assumingly a healthly heart? I have yet to start cardiology so curious. I know PVC's are from irritable foci originating in the ventricles and can be caused by hypoxia and certain drugs and sometimes infrequent PVC's are considered benign.


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## Ridryder911 (Jul 7, 2009)

usafmedic45 said:


> Not at all. It could well be a PAC with aberrent (abnormal) conduction. You can technically have PSVT with aberrant conduction that looks for all the world like ventricular tachycardia.  Just because it is wide, does not mean it's ventricular in origin.



Not denying the need, but sometimes one cannot see the trees for the forest. If I was testing you on ECG strips for the NREMT would you inform me, you would have to have a 12 lead before making an interpertation? 

You would fail. 

Sorry, I do respect your opinions and do understand your basis for obtaining this; but I believe we are clouding a rather simplistic ECG. 



ResTech said:


> What are some possible causes of PVC's in a 13 y/o with assumingly a healthly heart? I have yet to start cardiology so curious. I know PVC's are from irritable foci originating in the ventricles and can be caused by hypoxia and certain drugs and sometimes infrequent PVC's are considered benign.



Your right many are just benign. Pediatrics have a high vagal tone as well as irritability, caffeine induced, etc.. 


R/r911


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## usafmedic45 (Jul 7, 2009)

> Pediatrics have a high vagal tone as well as irritability, caffeine induced, etc..



I was going to go "Did he drink a Red Bull before this?".



> If I was testing you on ECG strips for the NREMT would you inform me, you would have to have a 12 lead before making an interpertation?
> 
> You would fail.



In that situation, I would assume it's a PVC and go from there.  In this case, we're looking at a non-significant finding (a single abberant beat does not tell us anything), and the quality of the EKG is not that great (no offense to the person who obtained it) so it is not going to change my assessment of the patient as I know it.


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## daughertyemta (Jul 7, 2009)

PVC's.  And I would agree.  You don't need a 12 lead to determine thats a pvc.  Thats why you have schooling.


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## Ridryder911 (Jul 7, 2009)

usafmedic45 said:


> ..." so it is not going to change my assessment of the patient as I know it".......



Yes, because we know we are going to treat the patient and not the monitor. 

R/r 911


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## firemedic31075 (Jul 8, 2009)

> Medic partner said it was a PAC, after quizzing me on it for a few minutes. Looks like a PVC in 3 to me, but then again I'm still learning.




I think your partner needs to brush up on his EKG's.


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## JeffDHMC (Jul 8, 2009)

It may be me, but the 1st wide complex does not look early. I must be wrong...right?


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## medic3416 (Jul 8, 2009)

JeffDHMC said:


> It may be me, but the 1st wide complex does not look early. I must be wrong...right?



The QRS complex is not early but take a look at the P-R intraval......
Good catch


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## mycrofft (Jul 9, 2009)

*Rid wins..."Treat the patient".*

By the way, not that uncommon for kids to be abusing epehdra, caffeine, and allied chemicals in "energy" products, OTC drugs, and even street drugs containing good or bad crank (meth). Most get over it. Some get hooked. Some find out they have WPW Syndrome.


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## firemedic31075 (Jul 9, 2009)

> Not at all. It could well be a PAC with aberrent (abnormal) conduction. You can technically have PSVT with aberrant conduction that looks for all the world like ventricular tachycardia. Just because it is wide, does not mean it's ventricular in origin.



True, but look at the ST segment and T wave. Usually with a PVC the T wave will deflect the opposite direction of the complex.


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## TomB (Jul 10, 2009)

I think the correct question is, "Are these PVCs or artifact?"

Tom


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## MSDeltaFlt (Jul 10, 2009)

Ridryder911 said:


> PAC's usually does not have compensatory pause as well as such as a wide QRS. Abberant PAC in set pattern as well is not the usual. I am surprised that you would request a 12 to determine a PVC or not...
> 
> R/r 911


 
I've been off of this thread for a while so I apologize for the reply delay.  The reason I would like to see a 12 Lead to determine the origin of this bizarre complex lies with the appearance of what looks like a possible P wave right before the complex in Lead I.  If all I had was Lead II or III, then I'd say yes.  It's a PVC.  Lead I, however, says "maybe, maybe not".

Reality check.  Let's step back and look at the big picture here.  It's only one complex.  Q: What does this have to do with the price of milk?  A: Absolutely nothing.  Translation: It's benign.  Even if I'm wrong on the interpretation.  It's not worth losing sleep over.

Just my humble and respectful thoughts to you sir.


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## Ridryder911 (Jul 10, 2009)

MSDeltaFlt said:


> Reality check.  Let's step back and look at the big picture here.  It's only one complex.  Q: What does this have to do with the price of milk?  A: Absolutely nothing.  Translation: It's benign.  Even if I'm wrong on the interpretation.  It's not worth losing sleep over.
> 
> Just my humble and respectful thoughts to you sir.



Oh, c'mon no Lido or better yet no Amiadorone?... C'mon I went all 5 months to Paramedic school! I gotta give something! .....


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## MSDeltaFlt (Jul 10, 2009)

Ridryder911 said:


> Oh, c'mon no Lido or better yet no Amiadorone?... C'mon I went all 5 months to Paramedic school! I gotta give something! .....


 
Touche', my friend.  Touche'.


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## Melbourne MICA (Jul 11, 2009)

*Hmm*

A lot of fuss over PVc's.

Do you have AVf? I'm interested to see if he has left axis deviation. 1 is up 3 is down but 2 is also up so probably a normal axis. So goes the inherent problems with just having a rhythm strip

A quick google for the differential for LAD however, makes good reading.

http://en.diagnosispro.com/differential_diagnosis-for/ekg-left-axis-deviation-ecg/28133-154.html

HHMmm


MM


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## fma08 (Jul 11, 2009)

Ridryder911 said:


> Oh, c'mon no Lido or better yet no Amiadorone?... C'mon I went all 5 months to Paramedic school! I gotta give something! .....



Or the 300mg Adeonsine one of my classmates suggested one time <_<

Anywho, do we have some more history on the kid? I'm leaning towards benign as well. So many teens chugging energy drinks and pop these days (I know, cuz I'm one of em). Also, any history of congenital problems?


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## Melclin (Sep 3, 2009)

Fusion beat from a end-diastolic PVC? Yes, no, maybe, way off?


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## MrBrown (Sep 3, 2009)

de-ja-vu all over agian; i remember something like this a couple weeks ago

My thoughts

1.  It's a PVC
2.  PVC's are mostly benign - esp for a 13yo
3.  No amiodarone!


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## wvditchdoc (Sep 7, 2009)

*Pvc*

I am going to go with it's a PVC, for what it's worth. That being said; I agree with the numerous posts stating that one random PVC *or* PAC is benign, so treat the patient not the monitor. 

Marc


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## medicnick (Sep 10, 2009)

Ridryder911 said:


> PAC's usually does not have compensatory pause as well as such as a wide QRS. Abberant PAC in set pattern as well is not the usual. I am surprised that you would request a 12 to determine a PVC or not...
> 
> R/r 911



Actually it is not uncommon to find extended R-R intervals following PACs. There are many examples of it available. This is one of those great EMS myths!

A wide QRS associated with a premature contraction is most likely going to be a PVC but it is also possible for it to be an aberrantly blocked ectopic atrial beat... that would be similar to a RBBB beat.

Cheers,
Nick


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## Ridryder911 (Sep 10, 2009)

medicnick said:


> Actually it is not uncommon to find extended R-R intervals following PACs. There are many examples of it available. This is one of those great EMS myths!
> 
> A wide QRS associated with a premature contraction is most likely going to be a PVC but it is also possible for it to be an aberrantly blocked ectopic atrial beat... that would be similar to a RBBB beat.
> 
> ...



Although, it can happen the chances in proportion I would not say is common or a myth rather an abnormality, alike A-Fib with third degree. 

R/r 911


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## medicnick (Sep 10, 2009)

Ridryder911 said:


> Although, it can happen the chances in proportion I would not say is common or a myth rather an abnormality, alike A-Fib with third degree.
> 
> R/r 911



Hi Ridryder,
It actually is not that uncommon. Those of us that work with implanted devices in cardiac patients daily do see this often. We/I may even see this more often than straight PACs.

One thing that is interesting is that the information available on a surface EKG whether a 3 lead or 12 lead is rather limited and depends on specific features to be available.

I would recommend that people keep an open mind and no matter what they may see on an EKG always consider that it may not be what they think it is. With just a simple EKG you can never be certain and once you think that you are 100% right something else will come along and trip you up.

Cheers,
Nick


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## Ridryder911 (Sep 10, 2009)

medicnick said:


> Hi Ridryder,
> It actually is not that uncommon. Those of us that work with implanted devices in cardiac patients daily do see this often. We/I may even see this more often than straight PACs.
> 
> One thing that is interesting is that the information available on a surface EKG whether a 3 lead or 12 lead is rather limited and depends on specific features to be available.
> ...



I agree, and point taken as well a good H & P will help eleminate some confusion as many patients do not always have implanted devices. 

As usual the old saying, _when you hear hoof beats think of zebras_...


R/r 911


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## fma08 (Sep 10, 2009)

medicnick said:


> Hi Ridryder,
> It actually is not that uncommon. Those of us that work with implanted devices in cardiac patients daily do see this often. We/I may even see this more often than straight PACs.
> 
> One thing that is interesting is that the information available on a surface EKG whether a 3 lead or 12 lead is rather limited and depends on specific features to be available.
> ...



What's that saying again? Give an EKG to 5 different cardiologists and you'll get 5 different interpretations... ^_^


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## medicnick (Sep 10, 2009)

fma08 said:


> What's that saying again? Give an EKG to 5 different cardiologists and you'll get 5 different interpretations... ^_^



That can also be true. If you are curious sometime, google "ekg core lab".

I have worked with the Duke Clinical Research Institute as an EKG core lab. Usually labs like this apply standard criteria to EKGs to have a high interreader reliability. People can still disagree on the diagnosis but usually it is only when they use a different criteria.

That is also true and many people don't realize it. There are a number of different algorithms used by computers and used by cardiologists to interpret EKGs.

One of the old standards is the Minnesota Code. You can read more about it at http://www.epi.umn.edu/ecg/ . Duke has their own algorithm for reading stress tests.

I work with a couple of the old time cardiologists including the coinventor of the Holter monitor... and work for the inventor of the original ICD and rechargable battery. Those pacemakers and defibrillators can last 30 years but they are not so popular now for some reason.

Cheers,
Nick


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