# Been meaning to post this strip for a while...



## jedirye (May 7, 2009)

Curious what you guys think. I can divulge more information a bit later, just curious to see what you guys are thinking at this point without any clues (ie. signs/symptoms).


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## DrankTheKoolaid (May 7, 2009)

*re*

mobitz 2, aka 2nd degree type 2, hell maybe even a 3rd now that i march it out


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## medic89 (May 8, 2009)

I'll agree with the 2nd Degree Type II, 2:1 conduction.....It's definitely not a 3rd Degree, all of the PRI's are the same.


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## emtjack02 (May 8, 2009)

I will echo the 2:1 AV Block


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## Melbourne MICA (May 8, 2009)

*Strip*

Its slow so brady. P waves are consistently attached to QRS and have same morphology so no AV dissociation and sinus node focus. Looks like every second beat is not coducted so that makes it a:

Sinus Bradycardia with 1:1 Mobitz Type 2 2nd degree AV block 

I think......

Why can't we just say - its going slow because some of the cylinders aren't working properly cause the fuel injectors are clogged.

MM


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## jedirye (May 8, 2009)

Dispatched as N/V with abdominal pain. 42 Y/W/F pt sitting on toilet (seat down, thank God) actively vomiting into trash bucket. Pt states that she's been vomiting for two days straight, almost to the point of dry heaving. Blood glucose elevated to 300mg/dL, no hx of diabetes. VS as stated. Rhythm as posted. Denies any shortness or breath, chest pain, or otherwise any other discomfort except as noted above (abdominal pain).

Update later after lab results, potassium at 2.8mEq/L.


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## DrankTheKoolaid (May 8, 2009)

*re*

Actually regardless of the regularity of the normal appearing P waves.  Pay close attention to the notching.  Not only is it not typical, that notched impulse follows a secondary pattern of regularity through out the entire strip.  Im still going with a block but this looks extremely similar to a Primary Aflutter with variably conducted ventricular beats

Corky


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## TomB (May 8, 2009)

jedirye said:


> Dispatched as N/V with abdominal pain. 42 Y/W/F pt sitting on toilet (seat down, thank God) actively vomiting into trash bucket. Pt states that she's been vomiting for two days straight, almost to the point of dry heaving. Blood glucose elevated to 300mg/dL, no hx of diabetes. VS as stated. Rhythm as posted. Denies any shortness or breath, chest pain, or otherwise any other discomfort except as noted above (abdominal pain).
> 
> Update later after lab results, potassium at 2.8mEq/L.



Yup! Thought so. Hypokalemia causes QT prolongation and the appearance of U waves. I don't think this is 2AVB.

Tom


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## omak42 (May 8, 2009)

TomB said:


> Yup! Thought so. Hypokalemia causes QT prolongation and the appearance of U waves. I don't think this is 2AVB.
> 
> Tom



usually wont you have a wide QRS with this also?


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## emtjack02 (May 8, 2009)

Nice strip, just goes to show it's not always what you think at first.


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## jedirye (May 8, 2009)

Once again, credit to Dr. Dubin.


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## omak42 (May 8, 2009)

so lets talk signs of hypokalemia on an EKG.  First the QRS widens, then your ST segment starts to depress, your T wave begins to flatten out, then you develop a U wave.  The more and more hypokalemic they become the bigger your U wave gets and the smaller your T wave gets.

Now lets talk what we see on the EKG as far as those are concerned......No wide QRS...machine says it is 0.088 and if you dont trust that then just look at them all....next ST depression, I dont see any of that either.  Flattened T wave....maybe slightly in some strips but not enough to get me thinking hypokalemia with all the other signs absent.  Now the U wave....you can argue that there is something after the T wave but you cant distinguish between a P wave and T wave.....so with all the other signs absent I would assume that those are P waves not T.  

Had you not been told that there serum potassium level was 2.8 I doubt any of you would be thinking hypokalemia...neither would I.  So interpreting that you could either come up with a 2:1 2nd degree Type 2, or a 3rd degree.

As far as QT prolongation......the QT is still within normal limits

And as if that werent enough the skips (missing QRS's) are not accounted for by the hypokalemia theory.

If anyone has evidence to dispute this please let me know cause I am very intrigued by this and would love all the education I can get


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## omak42 (May 8, 2009)

any muscle weakness?  anything else to suspect DKA?  any use of diuretics/any significant medical hx?


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## JeffDHMC (May 8, 2009)

QRS of 0.088 would make that 2nd dergree a bit of a zebra I think.


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## omak42 (May 8, 2009)

definitely with a 3rd degree.....but it could be a 2nd degree if they block is in the Bundle of His versus the bundle branches
but you got me to thinking and it couldnt be a 3rd degree due to the lack of a wide QRS....thanks for pointing out my oversight Jeff


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## DrankTheKoolaid (May 8, 2009)

*re*

Yeah im not going with the hypokalemia on this as there is just to much else going on.  Im certainly not even trained in EKG other then what we learned in medic school and what i've read on my own.  But after some more reading on hypokalemia this certainly doesnt fit. It doesn't account for the secondary rhythm which can be marched out as notches along the entire length of the strips.


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## omak42 (May 8, 2009)

i definitely agree.....even tho the hypokalemia leads to an interesting diagnosis....im thinking the way it marches out would definitely point towards a 2:1 Mobitz.....either way the lesson learned is dont always trust what your machine says as far as rhythm interpretation.  it said a mobitz 1.....it definitely is not


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## Melbourne MICA (May 8, 2009)

*another look*

I try to look at the clearest part of any ECG. Strips with atifact are not reliable. So the original 12lead in leads II,III, V4-V6 are nice and clean. They show a clear sinus beat and a p wave march mapped out that has each second beat not conducted. I dont beleive these are U waves nor do i think its a flutter as the rate is wrong - 50bpm. Flutters should be multiples of 75yes?

The other feature is that somesinus beats are coming in early. The progression thus is p wave, QRS, p wave, no QRS etc. But the early beats are bugging me. Perhaps another atrial focus that is also kicking in from time to time?

Why did this poor woman endure two days of nausea and vomiting without seeking help?

I still reckon its a second degree block.

MM


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## DrankTheKoolaid (May 8, 2009)

*re*

Not so on the flutter, i had an interesting A-flutter about 2 weeks ago.  Rate of 64 but irregular.  I actually called it a 2nd type 1.  Cardiologist i brought the patient to called it a A flutter with a 2-1 pre-weinkeback.  What i suspected were U wave were actually a flutter wave. 

http://books.google.com/books?id=_v...X&oi=book_result&ct=result&resnum=2#PPA416,M1 

 this link will bring you to almost a mirror of my patients strip.

Corky


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## Melbourne MICA (May 8, 2009)

*Flutterrrrrrrrr*

Corky

I couldn't load the page you mentioned but did a quick google to the American heart Association page on flutter.

Here's the link:http://www.americanheart.org/presenter.jhtml?identifier=52

Your's is an interesting take on the strip. I still think it's too slow (the p wave rate ) to be flutter but will stand corrected. Here to keep learning after all. 

MM


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## DrankTheKoolaid (May 8, 2009)

*re*

oh me also mica, that's why i love these discussions.  Keep's me from pigeon holing myself into specific thought patterns. Link didnt work eh?

type this into google, third link down


"a flutter wenckebach"


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## omak42 (May 9, 2009)

but does anyone see any sort of wave that would lead you to think a flutter?

i have to agree with corky...very interesting these things are


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## Melbourne MICA (May 9, 2009)

*The plot thickens*



Corky said:


> oh me also mica, that's why i love these discussions.  Keep's me from pigeon holing myself into specific thought patterns. Link didnt work eh?
> 
> type this into google, third link down
> 
> ...



Thanks Corky - looks like plate 469 was the one you were looking at. Pretty close match. I haven't had a chance to explode the view for a closer look or read the text yet but looks like the plot thickens. All good stuff nicht wah?

MM


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## TomB (May 9, 2009)

omak42 said:


> Now lets talk what we see on the EKG as far as those are concerned......No wide QRS...machine says it is 0.088 and if you dont trust that then just look at them all....next ST depression, I dont see any of that either.  Flattened T wave....maybe slightly in some strips but not enough to get me thinking hypokalemia with all the other signs absent.  Now the U wave....you can argue that there is something after the T wave but you cant distinguish between a P wave and T wave.....so with all the other signs absent I would assume that those are P waves not T.



There's no doubt in my mind that they are U waves.



omak42 said:


> Had you not been told that there serum potassium level was 2.8 I doubt any of you would be thinking hypokalemia...neither would I.  So interpreting that you could either come up with a 2:1 2nd degree Type 2, or a 3rd degree.



Actually, you should immediately consider hypokalemia for any patient with vomiting or diarrhea x2 days. I suspected hypokalemia when I saw the ECG and the story confirmed it (for me). It's always a good idea to interpret an ECG in light of the history and clinical presentation. The most likely explanation is usually correct. Sometimes I look for zebras, but that's when the clinical picture doesn't lend itself to an obvious answer.



omak42 said:


> As far as QT prolongation......the QT is still within normal limits



The computer is not measuring the QT interval correctly.



omak42 said:


> And as if that werent enough the skips (missing QRS's) are not accounted for by the hypokalemia theory.



Don't read too deeply into the irregularity. With 2AVBII the "skipped" beat would be 2x the previous R-R.


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## maxwell (May 9, 2009)

TomB said:


> Yup! Thought so. Hypokalemia causes QT prolongation and the appearance of U waves. I don't think this is 2AVB.
> 
> Tom



I'm going to give an Amen to Mobitz II.  

(i)  This rhythm may (or may not) present with a wide QRS [which is an ominous sign] - either way, they will need to be paced if this isn't from some weird drug toxicity (lopressuh, dig, dilt, etc)

(ii)  The hypokalemia shouldn't make us that worried right now.  People don't arrest dead in front of  us from a low K+.  (Now, Mg++, that's a different story)  - but yes - it does present with a long QT.  This isn't a long enough QTc to make us worry that the french are coming...


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## TomB (May 9, 2009)

I, for one, _would_ worry that the "french were coming" with a QTc = or > 500 ms! At least, I wouldn't be surprised! It would certainly modify my treatment plan for poly VT.

Tom



maxwell said:


> I'm going to give an Amen to Mobitz II.
> 
> (i)  This rhythm may (or may not) present with a wide QRS [which is an ominous sign] - either way, they will need to be paced if this isn't from some weird drug toxicity (lopressuh, dig, dilt, etc)
> 
> (ii)  The hypokalemia shouldn't make us that worried right now.  People don't arrest dead in front of  us from a low K+.  (Now, Mg++, that's a different story)  - but yes - it does present with a long QT.  This isn't a long enough QTc to make us worry that the french are coming...


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## jedirye (May 13, 2009)

Anyone else?


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## DrankTheKoolaid (May 13, 2009)

*re*

hrmm was hoping a expert would pipe in also.


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