# Guess the EKG



## Aidey (Mar 12, 2012)

60 yo female, dizzy. 

I'll post the 12 lead and more info in a bit.

And if anyone can tell me how to attach it so that you can zoom in without a huge file showing up in the post I will greatly appreciate it.


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## VFlutter (Mar 12, 2012)

I am leaning towards Aberrant Atrial Flutter or an Antidromic AV Reentrant Tach instead of  V tach


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## Brandon O (Mar 12, 2012)

1:1 flutter.

Saw a good case report about one of these in an infant a while back. Gnarly stuff.


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## Aidey (Mar 12, 2012)

Brandon Oto said:


> 1:1 flutter.
> 
> Saw a good case report about one of these in an infant a while back. Gnarly stuff.



Spoil sport  I'll still post the 12 lead. 

The pt was quite stable considering. Conscious, able to answer questions, radial pulse, EtCO2 of 25 mm/hg.


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## Aidey (Mar 12, 2012)

ChaseZ33 said:


> I am leaning towards Aberrant Atrial Flutter or an Antidromic AV Reentrant Tach instead of  V tach



Why abberant?


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## Brandon O (Mar 12, 2012)

Aidey said:


> Why abberant?



I presume he means aberrant conduction. 1:1 AV conduction, at this rate, is by definition inappropriate, and usually implies an accessory pathway.

I think this is the first elderly patient I've seen with this rhythm; nice strip. Would love more info on the case if you can.


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## Aidey (Mar 12, 2012)

I assumed that was what he meant, I'm curious why. Abberant conditions are typified by wide complex QRSs and this one is narrow.


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## Brandon O (Mar 12, 2012)

Looks borderline to me, right around 120.


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## Flyhi (Mar 12, 2012)

Any way you can post a link to the report ??





Brandon Oto said:


> 1:1 flutter.
> 
> Saw a good case report about one of these in an infant a while back. Gnarly stuff.


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## Brandon O (Mar 12, 2012)

Flyhi said:


> Any way you can post a link to the report ??



I would... but it seems to have disappeared. It was at ERStories.com, this url: http://erstories.net/archives/3700

Fortunately the Wayback seems to have it: http://web.archive.org/web/20110620144717/http://erstories.net/archives/3700


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## Flyhi (Mar 12, 2012)

Thanks a million


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## Aidey (Mar 12, 2012)

Brandon Oto said:


> Looks borderline to me, right around 120.



Counting the flutter wave sure. If someone wants to bust out a geometry book I bet we can figure out the actual width of the QRS and I'm guessing it is around .06.


I've attached the 12 lead.


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## EMSrush (Mar 12, 2012)

Any thoughts on the extreme right axis deviation?


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## VFlutter (Mar 12, 2012)

Aidey said:


> I assumed that was what he meant, I'm curious why. Abberant conditions are typified by wide complex QRSs and this one is narrow.



I was looking at this on my phone and it looked a little wide to me, but you are right it usually implies a wide complex QRS but as I understand it can also mean abnormal conduction such as the 1:1. 

Also here is a good picture I found on Google


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## VFlutter (Mar 12, 2012)

EMSrush said:


> Any thoughts on the extreme right axis deviation?



Just some random guesses (Not too much experience with EKGs )

-Possible history of COPD/Pulmonary hypertension. Seems to go along with that whole chain of events with cor pulmonale. Chronic Pulmonary hypertension leads to the RAE/LVH which usually leads to atrial arrhythmia (A fib/ Flutter) And the Right Axis. 
- Or I think WPW can create Right axis deviation which may tie into that 1:1 conduction or preexcitation going on.


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## Mavrande (Mar 12, 2012)

Aidey said:


> 60 yo female, dizzy.
> 
> I'll post the 12 lead and more info in a bit.
> 
> And if anyone can tell me how to attach it so that you can zoom in without a huge file showing up in the post I will greatly appreciate it.



I don't get how this is guessing - I hope you don't tell your patients "I think you'll be OK, but really I'm just making a guess"...

Wide complex regular tachycardia at a rate of just under 300. That's VT until proven otherwise, but given the P waves I would guess atrial flutter with a bundle branch block.


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## Aidey (Mar 12, 2012)

Well, considering I already know what it is, I wasn't the one guessing, you guys were. However, someone got it in the second post, so not much guessing going on. 

It is not wide. It is 1:1 flutter with the flutter wave buried in the beginning of the QRS.


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## MSDeltaFlt (Mar 13, 2012)

Aidey said:


> 60 yo female, dizzy.
> 
> I'll post the 12 lead and more info in a bit.
> 
> And if anyone can tell me how to attach it so that you can zoom in without a huge file showing up in the post I will greatly appreciate it.



All the articles you've posted refer to pediatrics. This pt is late middle aged. In all three leads there appears to be a near verticle wave form indicating the QRS which is why, without a 12 lead, I'm going with SVT.


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## mycrofft (Mar 13, 2012)

What were the clinical presentation, primary complaint, and the outcome?


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## Aidey (Mar 13, 2012)

The 12 lead is a few posts up. The pt self converted to 2:1 flutter before we had a chance to do anything. The rate went from 280 to 140.


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## MSDeltaFlt (Mar 13, 2012)

Aidey said:


> The 12 lead is a few posts up. The pt self converted to 2:1 flutter before we had a chance to do anything. The rate went from 280 to 140.



There it is.  Yeah, I would call it A Flutter at 2:1 even at that rate.  If you look closely the waves right before the complexes are the exact same shape as those right after.  And since they're all uniform, they must be the same wave. 

However, I'd still call it in the field as SVT since and treat it as such.


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## Brandon O (Mar 13, 2012)

MSDeltaFlt said:


> There it is.  Yeah, I would call it A Flutter at 2:1 even at that rate.  If you look closely the waves right before the complexes are the exact same shape as those right after.  And since they're all uniform, they must be the same wave.
> 
> However, I'd still call it in the field as SVT since and treat it as such.



I am extremely tickled by this possibility, as there has been something bothering me about this strip, and the "extra" bumpies are a large part of it. They do seem to march out, sort of, and the morphologies sort of match. However, flutter at an atrial rate of *600*, with a ventricular rate of *300*, in a *60* yo patient... well, I'm not sure there's much (except good bourbon) that can make me swallow that.


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## 8jimi8 (Mar 13, 2012)

Brandon Oto said:


> I am extremely tickled by this possibility, as there has been something bothering me about this strip, and the "extra" bumpies are a large part of it. They do seem to march out, sort of, and the morphologies sort of match. However, flutter at an atrial rate of *600*, with a ventricular rate of *300*, in a *60* yo patient... well, I'm not sure there's much (except good bourbon) that can make me swallow that.



what is wrong with those rates?   what phenomenon of ectopy initiates the increased atrial rates in the first place?


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## VFlutter (Mar 13, 2012)

8jimi8 said:


> what is wrong with those rates?   what phenomenon of ectopy initiates the increased atrial rates in the first place?



I think he is referring to the comment about SVT (Even though technically A flutter can fall under the category of supraventricular Tach). I would be suspecting A flutter not SVT such as AVNRT, AVRT, or some other nodal reentry rhythm.


Also I am curious how you would treat this in regards to calling it SVT, are you considering Adenosine?. I am still hung up on the possibility of the patient having WPW leading to the 1:1 conduction which would fall into the category of preexcited A flutter. What did the 2:1 flutter look like? Delta wave?


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## Aidey (Mar 13, 2012)

I'm confused what you mean about the waves right after looking the same as the waves before. The only lead with a retrograde flutter wave is lead aVr.


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## MSDeltaFlt (Mar 13, 2012)

Aidey said:


> I'm confused what you mean about the waves right after looking the same as the waves before. The only lead with a retrograde flutter wave is lead aVr.



Be advised I am looking at this with my phone.  But if you look at the P waves and the S waves in I, II, aVf, V5, & V6 the wave shapes all match.  At rates that fast P waves, S waves, nor T waves are supposed to look alike.  So, at rates that fast, if the waves look the same then odds are they will be the same.

Itself the opposite side of the same coin to determine WAP, where 3 or more P waves do not look the same Because they are originating from different places.

And yes I would treat with Adenosine unless I already knew their PMH.  ECG is too fast to say WPW.  But have your pads on them just in case.  That is if they're symptomatic (depending on BP) in which case I'd try vagals, open fluids up (if lungs clear), give meds, then shock if not earlier depending on BP.


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## Aidey (Mar 14, 2012)

Ok, I'm still confused. The whole complex in leads II and aVF look similar to each other, and the whole complex in leads V4-V6 look similar to each other but none of them are identical. I really don't understand what you mean by the S waves and T waves all looking alike. The only thing I can come up with for matching S waves is that they are all close to an 80 degree angle to the isoelectric line. I can barely even discern a T wave in that 12 lead.


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## MSDeltaFlt (Mar 14, 2012)

What I mean is this. Look closely at the very top portion of each of those waves in those leads. They have similar humps/curves.  Granted it is extremely difficult to look at them via cell phone regardless of pixel clarity and also at those rates.  But to my eyes they look similar. Does it matter at those rates?  Not really. At those rates you treat the rhythm symptomatically according to your protocols. It's still SVT any way you look at it because it is still a SUPRAventricular tachycardia.  

The exact diagnosis is done after the call as you're charting and discussing with the MD, RN, and other medics,et al at the water cooler.


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## Christopher (Mar 14, 2012)

As many folks pointed out, this is 1:1 atrial flutter and WPW. The shortest R:R is less than 260ms, which all but seals the diagnosis of an accessory pathway in someone 60 years of age! Even in the absence of frank delta-waves (which do not have to be present for an AP to exist), there exists no other explanation.

If they were instead 60 days old, perhaps another etiology is possible.

The likelihood of this being VT is all but absent given the rate, but it also could not be definitively ruled out. Anecdotally I have seen case reports of VT in the 250-260 range, but never higher.

SVT when used in the general sense is "correct" in that this is a rapid narrow complex rhythm originating in the atria, but in the specific sense this could not be AVNRT or AVRT (neither orthodromic nor antidromic). The AVN will simply not allow conduction at those rates and those reentry rhythms all require the AVN!

Once your rate tops about 220-240 (age dependent of course), you simply must assume that an AP is present and treat accordingly. With 1:1 conduction over an AP present, adenosine certainly will not solve the problem. Ca-channel blockers and B-blockers are also absolutely contraindicated.

Procainamide is often quoted as "safe in WPW", but with a rhythm like atrial flutter as the mechanism, you could run into trouble. While procainamide will slow conduction through the AVN and AP, it will also slow the flutter circuit which potentially could dip into the range conductible by the AVN!

I think the only course of action in an unstable patient with 1:1 atrial flutter is cardioversion. I agree with Tom that if we could, I would take a ride with this patient and monitor them. Otherwise, I would sedate and cardiovert.

I've attached an example of a 1:1 flutter I mistakenly treated as VT with lidocaine, prior to my introduction to proper WCT treatment, which thankfully ended up working.

Great case!


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## Melbourne MICA (Mar 21, 2012)

*Dizzy*

Atrial flutter 1:1 

A rate @ 300/min (new QRS every 1 lrge square) and a narrow complex saw tooth pattern suggest the rhythm is above the junction. Such a rate is unlikley to be sustained in the ventricles.


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