# EKG Rhythm Strips



## VFlutter (Mar 18, 2012)

Hey guys, Attached is a PDF of some telemetry strips showing a few different rhythms, nothing too interesting mostly just basic stuff. I finally found a way to capture the strips directly off our monitors instead of printing  then scanning them which never turned out right. I will try to get some more interesting rhythms next time I work. If anyone has a specific rhythm they have been trying to get a copy of let me know. We usually get a couple codes a month so I will try to get some arrest rhythms. Sorry if they are not the best quality.


----------



## VFlutter (Mar 18, 2012)

Also, Please let me know your opinions on Page 6 strip #2. Me and the Nurse disagreed on that. She said that they were transferred from the ICU and the report stated they were in A Fib w/ SVR and the EKG showed A Fib however I think it is too regular to be A Fib and some of the T waves look like they may have retrograde P waves buried in them so I charted it as Questionable Junctional Rhythm


----------



## Handsome Robb (Mar 18, 2012)

ChaseZ33 said:


> Also, Please let me know your opinions on Page 6 strip #2. Me and the Nurse disagreed on that. She said that they were transferred from the ICU and the report stated they were in A Fib w/ SVR and the EKG showed A Fib however I think it is too regular to be A Fib and some of the T waves look like they may have retrograde P waves buried in them so I charted it as Questionable Junctional Rhythm



Agreed, I'd personally call it a junctional rhythm not A-Fib with SVR. I don't see how anyone could call it "irregularly irregular", I only saw one beat that was irregular but even then it's pretty close to falling within limits of being "regular" per the text books.

I'd love to see some A-flutter that doesn't beat you over the head with flutter waves haha.


----------



## Aidey (Mar 18, 2012)

Look at the "Guess the EKG" thread, lol.


----------



## Handsome Robb (Mar 18, 2012)

Aidey said:


> Look at the "Guess the EKG" thread, lol.



No that ECG made me cry. h34r: I was totally off on what I thought it was and it hurt my feelings


----------



## VFlutter (Mar 19, 2012)

NVRob said:


> Agreed, I'd personally call it a junctional rhythm not A-Fib with SVR. I don't see how anyone could call it "irregularly irregular", I only saw one beat that was irregular but even then it's pretty close to falling within limits of being "regular" per the text books.
> 
> I'd love to see some A-flutter that doesn't beat you over the head with flutter waves haha.



Look at page 4 #3, That is technically Atrial Tachycardia with a Variable AV block due to the atrial rate (150-200ish). If it was around 250-350 it would be A flutter. It took me a minute to figure it out since you only rarely see the extra P waves.

That is the same patient on page 1 #3. They were going in and out of that variable AV block with Runs of Junctional Tach.


----------



## Handsome Robb (Mar 19, 2012)

ChaseZ33 said:


> Look at page 4 #3, That is technically Atrial Tachycardia with a Variable AV block due to the atrial rate (150-200ish). If it was around 250-350 it would be A flutter. It took me a minute to figure it out since you only rarely see the extra P waves.
> 
> That is the same patient on page 1 #3. They were going in and out of that variable AV block with Runs of Junctional Tach.



That's a very angry heart. Ok maybe not angry, lets go with agitated. Ok maybe angry :lol:


----------



## VFlutter (Mar 25, 2012)

Torsades de Pointes with an AICD firing.


----------



## systemet (Mar 25, 2012)

I think page 6, #2 is a little hard to define based on two leads -- I'd rather see a 12-lead.  That being said, I think some consideration needs to be given to whether this is AIVR.  The lead II tracing is almost entirely negative, with only a small initial R.  This suggests that the axis is somewhere around -120 +/- 30 degrees, which is quite extreme for a supraventricular rhythm, even if aberrantly conducted.  

I know if doesn't look that wide, but some of this rhythms look pretty marginal for QRS prolongation, if you just pick a couple of leads.

The T waves look weird.  I guess it's possible that there's P waves buried in there (which would exclude AF), but we don't see any appear during the long T-P intervals.  So this could also be a junctional rhythm with LAHB, especially if other limbs leads suggest the axis is closer to 90 degrees.  But I'm still not quite sure what to make of the T waves.  I guess it could be argued that the atrial rate approximately = the ventricular rate. But in practice this is uncommon.


----------



## TomB (Mar 25, 2012)

ChaseZ33 said:


> Also, Please let me know your opinions on Page 6 strip #2. Me and the Nurse disagreed on that. She said that they were transferred from the ICU and the report stated they were in A Fib w/ SVR and the EKG showed A Fib however I think it is too regular to be A Fib and some of the T waves look like they may have retrograde P waves buried in them so I charted it as Questionable Junctional Rhythm



1:1 VA conduction does not necessarily make it junctional. It could just as easily be ventricular but I agree it's not AF.

Tom


----------



## TomB (Mar 25, 2012)

ChaseZ33 said:


> Torsades de Pointes with an AICD firing.



Cool strips! Thanks for sharing.

Tom


----------



## VFlutter (Mar 26, 2012)

Some more strips :beerchug:


----------



## Craig Alan Evans (Apr 1, 2012)

Keep them coming. This is great to show to our interns and newer paramedics.  I agree on Page 6 #2, but don't forget that you can have a 3rd degree block with a-fib and it will be regular, albeit wider QRS though. Great stuff.  Thanks!


----------



## FLdoc2011 (Apr 1, 2012)

Pretty straightforward but a good example nonetheless......


----------



## Christopher (Apr 2, 2012)

That's a pretty fast A-Flutter, but gorgeous saw-tooth waves! Looks almost at a rate of 320-340ish.


----------



## FLdoc2011 (Apr 2, 2012)

Yea,  pt I had on the wards here.  Initially wasn't sure if SVT or flutter and gave some adenosine with the above findings.


----------



## TomB (Apr 2, 2012)

Even better! So what did you do after the experiment proved it was flutter?

Tom


----------



## FLdoc2011 (Apr 2, 2012)

Trying I remember, I think in this case we may have ended up chemically converting with ibutilide.  Otherwise stable so no need for cardioversion.    Lately out cardio folks have enjoyed using ibutilide for fib/flutter.


----------



## VFlutter (May 7, 2012)

A few from last night :deadhorse:


----------



## Christopher (May 7, 2012)

ChaseZ33 said:


> A few from last night :deadhorse:



Neat.

Looks like some 2:1 2AVB, then a PVC inhibits vent response so you get an escape beat before it finally picks up again. Could be a mix of Type I and Type II, but the first strip certainly looks to have a fixed PRi for all but QRS complexes 5 and 6.

The second strip appears to be 3AVB or a high degree AVB with couplet PVCs at the end (or perhaps reciprocal beats).

Third strip is 3AVB or high degree AVB with various escapes and PVCs.

Fourth strip looks like 2:1 AVB with some degree of ventricular fusion during a run of PVCs. Fifth strip appears to have increasing ST-E from the 4th strip in the V lead.

Sixth strip looks like ST w/ PVCs turning into either PSVT or AF w/ RVR (difficult to tell on this screen).

Seventh/eighth strip looks like AIVR, although I can't explain the slowing and speeding up, before converting to NSR.


----------



## VFlutter (May 7, 2012)

I definitely had to brush up on my heart blocks last night. The first 3 strips are the same patient. Patient was admitted in Atrial Flutter 120's then converted into sinus a few hours later (Not sure what meds were given). Ever since they converted they  had various blocks. They would go back and forth between 2nd degree type 1 and 2 and then started to look more like High Degree/Advanced or complete. In the 3rd strip you can see a junctional escape and then a P wave fusing into the last QRS.

7th and 8th strips confused me a little. It looks Junctional or Ventricular but is fairly irregular. Also I see a lot of patients with rate dependent BBB, can you go into a junctional rhythm and then have a bundle change during that rhythm only?


----------

