# EKG no one can figure out.



## Aidey (Jul 9, 2011)

These EKGs are from a patient of mine. I was unable to follow up on her, so I do not know what the cardiologist called it. However, no paramedic or ED Doc has been able to conclusively call it anything. 

~350lb, 63 yo female, called for shortness of breath at a private residence. 

HPI: The patient reports that she has been having increased SOB for the last few days. She was recently (4-5 days ago) diagnosed with a UTI and is taking an unknown oral antibiotic for it. She can not recall having SOB to this degree before. 

ROS: (+) Feeling feverish, temp of 100.6 today. Denies lightheadedness, dizziness, headache, vision disturbances. Denies cough, productive or not. Denies chest pain. (+) SOB, especially on exertion. Denies nausea, vomiting or diarrhea. (+) Increasing pedal edema over the last month. 

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. 

Allergies: Morphine, CDN, PCN, Sulfa

Meds: Duonebs q4hrs, Albuterol PRN, Advair, Lisinopril, Levothyroxine, Glipizide, Metformin, Novolog, Lantus, Simvastatin, ASA, and an antirejection med I can't remember the name of. 

Vitals: P - 60. R - 28-34, labored. Bp - 160/88. Lungs - Diminished, but clear. Room SpO2 - 80%. SpO2 on 10lpm 97%. Co2 - 40 mm/hg. CBG - 216 mg/dl. 

It is very important to look at both. 

Here is the 12 lead

And here is the 3 lead


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## mycrofft (Jul 9, 2011)

*Litella maneuver this comment*

"Never Mind"


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## luke_31 (Jul 9, 2011)

Looks like a sinus rhythm with a first degree heart block and p-mitrale. R wave progression is abnormal. Normal Axis deviation.

Judging by the pt's history I would say she has a very sick heart and would be cautious with providing treatments that would make the heart work harder as it already is struggling.


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## Aidey (Jul 9, 2011)

How do you explain all those p waves without a corresponding QRS? Or the P waves buried in the preceding T waves? Or the change in QRS morphology (negative deflection to positive deflection)?


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## STXmedic (Jul 9, 2011)

My shot:

2nd degree Type 2 with a LBBB, LAE, and Anterior-Lateral MI

Edit: Though V1 suggests RAE as well...


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## STXmedic (Jul 9, 2011)

Normal axis. Starts off with a mildly normal though slightly delayed R wave progression, but drops off to Q waves, suggesting necrosis

/facepalm.... Maybe if I would read and not jump straight to the 12 lead  PCCs at the start of the 3 lead for sure. That's the best I've got


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## Aidey (Jul 9, 2011)

PoeticInjustice said:


> Normal axis. Starts off with a mildly normal though slightly delayed R wave progression, but drops off to Q waves, suggesting necrosis
> 
> /facepalm.... Maybe if I would read and not jump straight to the 12 lead  PCCs at the start of the 3 lead for sure. That's the best I've got



Yeah, you HAVE to look at the 3 lead, it gives nearly as much info as the 12 lead does. I'm assuming you mean PVCs? 

In a 2nd degree, Type II block wouldn't the QRS-T complex end prior to the next P wave starting? If those are PVCs, you also don't often see buried P waves. In both versions of the QRS there are buried P waves in the T waves. 

An interesting thing to note is that the P waves march out at ~120 bpm, and the QRS complexes march out ~60 bpm. That makes it a little harder to tell if there is actually an association between the P waves and QRS complexes, or if it is a crazy coincidence that they seem to line up in some way. 

Another interesting thing is that when she switched from the positive QRS complexes to the negative complexes there were always 4-5 of the P waves without any QRS complexes before the negative complexes started up. 

I tried to get 12 leads of the two different QRS complexes, but I wasn't successful. She went back and forth a number of times.


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## STXmedic (Jul 9, 2011)

Aidey said:


> Yeah, you HAVE to look at the 3 lead, it gives nearly as much info as the 12 lead does. I'm assuming you mean PVCs?
> 
> In a 2nd degree, Type II block wouldn't the QRS-T complex end prior to the next P wave starting? If those are PVCs, you also don't often see buried P waves. In both versions of the QRS there are buried P waves in the T waves.
> 
> ...



I'm sure Tom will correct me if I'm wrong, but the ventricular repolarization won't have any affect on the atrial depolarization. The fact that it's 120:60 really makes me think Type 2 with a 2:1 conduction delay. If the change to negative complexes are preceded by multiple P waves with no QRS, I think her block is progressing to a complete block. The switch to negative deflection complexes (PVCs) would be from the ventricular escape 2/2 the complete heart block. Once the beats start going back through the block at 2:1, the ventricular escape ceases, switching back to positive complexes. A previous 12 lead would be wonderful (obviously not likely for you to have) to see if the Q waves laterally are new or old. If new, could explain the possibly new onset LBBB and intra-nodal block


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## luke_31 (Jul 9, 2011)

Aidey said:


> How do you explain all those p waves without a corresponding QRS? Or the P waves buried in the preceding T waves? Or the change in QRS morphology (negative deflection to positive deflection)?



Not paying close enough attention and a bit tired


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## sir.shocksalot (Jul 9, 2011)

PoeticInjustice said:


> My shot:
> 
> 2nd degree Type 2 with a LBBB, LAE, and Anterior-Lateral MI
> 
> Edit: Though V1 suggests RAE as well...



I would consider a rate dependent block or an escape rhythm also. There is a p wave for every qrs but not a qrs for every p wave. The change in morphology is tough to explain, especially since there are still p waves before complexes. 

That said, t wave discordance and elevation in the anterior leads is normal in a LBBB and not indicative of ischemia or infarction.

Very interesting 12 lead, hopefully an expert will jump on here and clear it up for those of us that apply electricity until the rhythm looks recognizable


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## Aidey (Jul 9, 2011)

The LBBB isn't new, she was the one who told me she had it. 

I agree that whatever it is, it is heading towards a complete block. Especially with her history of a heart rate intermittently the 30s. 

As near as I can tell from some quick research a 2nd degree Type II generally repolarizes normally, meaning there will be a distinct T wave separate from the P wave.  

When I scanned the EKGs I made the files huge, so I could blow them up and examine them closely. On the 3 lead the PRI is NOT constant, for either the positive or negative QRS complexes. It is very close, but when you've got it blown up so that each QRS is 3 inches tall it becomes much easier to see.

Edit: If anyone wants those huge files to take a look on their own, or to use in a class send me a PM.


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## TomB (Jul 9, 2011)

Today is my last day of vacation in Northern Michigan and I have to come back home to the grind today. Ugh! Anyone have a suggestion for early onset post-vacation depression???

Anyway, it appears this patient has a very sick heart and a pacemaker with the lower rate limit set to just under 60. The rhythm strip shows 2:1 pacing with intrinsic AV conduction overtaking the paced rhythm. Take a VERY close look at the PR-intervals and R-R intervals to see what I'm talking about. When the patient's own heart rate hits 60 the pacemaker stops pacing.

At first I thought the 12-lead ECG showed 2:1 pacing but I looked at that prior to the rhythm strip. It shows untypable 2:1 block with nonspecific IVCD (LBBB morphology in lead V1 but negative concordance in the precordial leads which is unusual for LBBB -- this is just nitpicking).

The slight concordant ST-elevation in lead III and slight concordant ST-depressioin in aVL would be enough to make me compare to an old ECG if the patient was complaining of any s/s suggestive of ACS.

Cool ECGs!

Now how about those tips for end-of-vacation anxiety?

Tom


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## Aidey (Jul 9, 2011)

She absolutely does not have a pacemaker, but she is scheduled for one very soon.

Edit: Trust me, I asked and looked. The FD had mentioned the pacemaker surgery on scene. When I hooked her up in the amb and saw that I said "So you are scheduled for a new pacemaker next week?" And she said no, she did not have a pacemaker, and has never had one.


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## TomB (Jul 9, 2011)

The rhythm strip speaks for itself but I'm certainly not going to get in an argument over it. Thanks for the interesting case!


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## Aidey (Jul 9, 2011)

TomB said:


> Anyway, it appears this patient has a very sick heart and a pacemaker with the lower rate limit set to just under 60. The rhythm strip shows 2:1 pacing with intrinsic AV conduction overtaking the paced rhythm. Take a VERY close look at the PR-intervals and R-R intervals to see what I'm talking about. When the patient's own heart rate hits 60 the pacemaker stops pacing.
> 
> At first I thought the 12-lead ECG showed 2:1 pacing but I looked at that prior to the rhythm strip. It shows untypable 2:1 block with nonspecific IVCD (LBBB morphology in lead V1 but negative concordance in the precordial leads which is unusual for LBBB -- this is just nitpicking).
> 
> ...



Also, that isn't concordant ST elevation, it is a buried P wave. I thought it was concordant elevation when I first saw it too, but on some of the strips you can see 2 tiny little peaks that match the other P waves.


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## Aidey (Jul 9, 2011)

Even if the patient was such a bad historian she forgot she had a pacemaker, I'm pretty sure her husband or RN daughter would have mentioned it rather than saying she was scheduled for surgery. 

If you PM me your e-mail address I can send you the large files so you can take a closer look at them. 

I don't want to argue either, I want to know what it is, and I know it is not a pacemaker.


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## TomB (Jul 9, 2011)

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.


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## MSDeltaFlt (Jul 9, 2011)

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


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## Too Old To Work (Jul 9, 2011)

TomB said:


> Today is my last day of vacation in Northern Michigan and I have to come back home to the grind today. Ugh! Anyone have a suggestion for early onset post-vacation depression???
> 
> Anyway, it appears this patient has a very sick heart and a pacemaker with the lower rate limit set to just under 60. The rhythm strip shows 2:1 pacing with intrinsic AV conduction overtaking the paced rhythm. Take a VERY close look at the PR-intervals and R-R intervals to see what I'm talking about. When the patient's own heart rate hits 60 the pacemaker stops pacing.
> 
> ...



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.


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## TomB (Jul 9, 2011)

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.


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## Aidey (Jul 9, 2011)

TomB said:


> 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? 




MSDeltaFlt said:


> 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. 




Too Old To Work said:


> 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.





TomB said:


> 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.


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## Too Old To Work (Jul 9, 2011)

Aidey said:


> 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. <_<


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## Aidey (Jul 9, 2011)

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.


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## Too Old To Work (Jul 9, 2011)

Aidey said:


> 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.


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## Dutch-EMT (Jul 15, 2011)

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.


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## Aidey (Feb 23, 2012)

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.


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