# EKG interp



## bigbaldguy (Nov 21, 2012)

What do you think.


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## VFlutter (Nov 21, 2012)

That's a tricky one with just that single lead, I would like a 12 lead. My DDx would include Vent paced with PVC, IVR with PVC, or 3rd degree with ventricular escape and underlying Atrial Fib. I think the last two are more likely. If you zoom in on the baseline it looks like a fine fibrillation but I suppose that could be artifact.


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## Handsome Robb (Nov 21, 2012)

Without a 12 I'd call it IVR with PVCs.

Just my .02


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## VFlutter (Nov 22, 2012)

NVRob said:


> Without a 12 I'd call it IVR with PVCs.
> 
> Just my .02



Don't sell yourself short! Your interpretation is worth at least a nickel



Oh and BBG stop stealing stuff of Facebook


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## Akulahawk (Nov 22, 2012)

To me, that kind of looks like a third-degree AV block with escape beats that are not perfusing. That is, of course, if the SpO2 wave is correctly timed to the EKG on the strip. If it is in fact a paced rhythm, I would really like to see where the pacer spikes are.

If the heart is contracting with those beats, I would imagine that the sensation, the patient would feel would probably feel somewhat akin to the heart skipping (like a kid skips on the playground) in the chest, where you feel to beats occur rapidly with a pause, then 2 rapid beats than a pause and 2 rapid beats, and then a pause. That could certainly cause the patient to describe a fluttering feeling in the chest, simply because it doesn't feel right, and perhaps "palpitations" is the closest thing that the patient could describe that as.

That baseline does look kind of like a fine atrial fibrillation…

Did I forget to mention that I'm kind of rusty at this?


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## Handsome Robb (Nov 22, 2012)

ChaseZ33 said:


> Don't sell yourself short! Your interpretation is worth at least a nickel
> 
> 
> 
> Oh and BBG stop stealing stuff of Facebook



Score!!!!

One thing I will say is if those, in fact, are PVCs they are reasonably close to the T wave and I'd be watching real closely for any R-on-Ts or movement in that direction. This has potential to go south quickly if it already hasn't. I'd love to know the patient's presentation. 

I personally don't think it's paced. I'd think you'd see pacer spikes even in a single lead but I'm also new as heck at this medic thing so take that for what it's worth. 

Akula, and Chase for that matter, I'm not sure I'm seeing this 3rd Degree AVB you both speak of. I do agree that the baseline looks like it has potential to be A-fib or was at one point recently before this disaster of a rhythm started.


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## VFlutter (Nov 22, 2012)

NVRob said:


> Score!!!!
> 
> One thing I will say is if those, in fact, are PVCs they are reasonably close to the T wave and I'd be watching real closely for any R-on-Ts or movement in that direction. This has potential to go south quickly if it already hasn't. I'd love to know the patient's presentation.
> 
> ...



I do not think this particular rhythm is paced but it would be on my differential to rule out. Sometimes pacer spikes can be very hard to see. With a 3rd degree AV block you have an atrial rhythm as well as an underlying escape rhythm which is usually junctional or ventricular. And IVR is basically just a ventricular rhythm without atrial activity. The most common atrial presentation is sinus, the multiple P waves, however you can also have atrial fib as the underlying atrial rhythm. This presents looking like a bradycardic wide complex ventricular rhythm which is very regular (Ruling out A fib) with atrial fibrillation inbetween the QRS complexes. So basically looks like IVR but with a fib inbetween instead of a straight isoelectric line. There is a complete AV block with the atria and ventricles doing their own thing. Or something like that, I am just getting off a night shift and am sleep deprived. 

Its fun watching patients with frequent PVCs on the monitor who also have an A-line. You can see the decreased cardiac output, if any, with the premature beats.




Here is a crappy example of a 3rd degree AVB with a junctional escape and underlying A Fib. Some of the leads look like A flutter so just ignore those lol (From Lifeinthefastlane)


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## Handsome Robb (Nov 22, 2012)

ChaseZ33 said:


> I do not think this particular rhythm is paced but it would be on my differential to rule out. Sometimes pacer spikes can be very hard to see. With a 3rd degree AV block you have an atrial rhythm as well as an underlying escape rhythm which is usually junctional or ventricular. And IVR is basically just a ventricular rhythm without atrial activity. The most common atrial presentation is sinus, the multiple P waves, however you can also have atrial fib as the underlying atrial rhythm. This presents looking like a bradycardic wide complex ventricular rhythm which is very regular (Ruling out A fib) with atrial fibrillation inbetween the QRS complexes. So basically looks like IVR but with a fib inbetween instead of a straight isoelectric line. There is a complete AV block with the atria and ventricles doing their own thing. Or something like that, I am just getting off a night shift and am sleep deprived.
> 
> Its fun watching patients with frequent PVCs on the monitor who also have an A-line. You can see the decreased cardiac output, if any, with the premature beats.



Ok, I see what you're gettin' at. I was so set on the picture perfect 3AVBs I've seen in books and the one and only that I've had in the field that was textbook looking. That makes sense though. 

Dude, I like to think of myself as being decent at interpreting ECGs but you run freaking circles around me.


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## VFlutter (Nov 22, 2012)

NVRob said:


> Ok, I see what you're gettin' at. I was so set on the picture perfect 3AVBs I've seen in books and the one and only that I've had in the field that was textbook looking. That makes sense though.
> 
> Dude, I like to think of myself as being decent at interpreting ECGs but you run freaking circles around me.



I was completely clueless the first time I actually saw it. I never even thought about the possibility of having a fib with a 3rd degree. It makes sense once you think about it. 

I never said I am right with any of this...I'm just an EMT


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## Handsome Robb (Nov 22, 2012)

Or a BSN about to graduate...but hey whatever way you like it hahaha

FWIW I'd almost be inclined to call that A-flutter but then again in other leads it's definitely A-fib.


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## TomB (Nov 22, 2012)

bigbaldguy said:


> What do you think.



The SpO2 waveform does not look contemporaneous with the ECG which seems odd.


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## VFlutter (Nov 22, 2012)

NVRob said:


> Or a BSN about to graduate...but hey whatever way you like it hahaha
> 
> FWIW I'd almost be inclined to call that A-flutter but then again in other leads it's definitely A-fib.



Until I have that degree in hand then EMT-B is my highest level of education lol

That is something I still have trouble with. Rhythms that I am sure are A futter are actually A fib according to cardiologist. It just depends on who you ask. I usually just stick with calling stuff A Fib/Flutter unless its text book perfect fultter. 

Here is a link to the website...http://lifeinthefastlane.com/ecg-library/junctional-escape-rhythm/


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## VFlutter (Nov 22, 2012)

On our telemetry monitors I think the spo2 wave form and EKG are a few beats off. Instead of looking at the pleth directly under the QRS I usually look at the next beat, kind of diagonal line to the right, and it matches up. That is just an observation so I am not sure how it is supposed to work.


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## Akulahawk (Nov 22, 2012)

TomB said:


> The SpO2 waveform does not look contemporaneous with the ECG which seems odd.


That was something that caught my eye as well. If all was functioning as it should, SpO2 waveform should occur normally just "after" or to the "right" of the QRS complex that results in a perfusing beat. Some of those waveforms seem to occur after the first complex in the pair, some occur after the 2nd complex in a pair.


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## bigbaldguy (Nov 22, 2012)

Thanks for the input all. Afraid I don't have any info on patient presentation just the strip.


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## Christopher (Nov 24, 2012)

bigbaldguy said:


> What do you think.



My rhythm diff would be A-fib with artifact or PVC's. Tough to say from just that rhythm strip. Those are extremely short coupled PVC's if they are in fact PVC's. Perhaps pseudo-regularized due to B-blockers.

Less likely is a complete heart block and atrial fibrillation (with artifact or PVCs), followed by AIVR and a competing ventricular focus.

The "PVCs" are narrower and lack T-waves, and given it has a same general amplitude as the confirmed QRS complexes, I find it hard to believe their T-wave axis would be perpendicular to the QRS axis. Most likely artifact.


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## Shishkabob (Nov 24, 2012)

The squigglies aren't squiggling right.


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## VFlutter (Nov 24, 2012)

Linuss said:


> The squigglies aren't squiggling right.



Better than not squiggling at all...


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## Merck (Nov 24, 2012)

ChaseZ33 said:


> Here is a crappy example of a 3rd degree AVB with a junctional escape and underlying A Fib. Some of the leads look like A flutter so just ignore those lol (From Lifeinthefastlane)



Sorry but this is definitely an A Flutter.


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## MJG (Nov 24, 2012)

TomB said:


> The SpO2 waveform does not look contemporaneous with the ECG which seems odd.



No P-Waves? Possible Sick-Sinus-Syndrome or AF? Combined with a bigmemnus? But then again, i'm just guessing...

Cheers!


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## zmedic (Nov 24, 2012)

Christopher said:


> .



Also the QRS is getting pretty wide. Maybe it's PVCs or a ventricular rhythm, but I would worry about things that widen the QRS like TCA overdose or hyperkalemia. It's getting a bit sine wavey. 

But the big thing is if you are going to look at a rhythm strip you should have 3 leads, and a longer strip, like 6-10 seconds worth, or a QRS. One lead is basically "is this Vtach/Vfib?"


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## Christopher (Nov 24, 2012)

Merck said:


> Sorry but this is definitely an A Flutter.



Too fast for flutter (and it is a bit irregular in morphology).


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## VFlutter (Nov 24, 2012)

Merck said:


> Sorry but this is definitely an A Flutter.



http://lifeinthefastlane.com/ecg-library/junctional-escape-rhythm/

Link to the description of the picture. As Chris mentioned the atrial rate is outside the A flutter range as well as the P wave morphology being a little irregular.


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## MSDeltaFlt (Nov 24, 2012)

As far as the 1st goes, can't say much without a 12 lead.  So with the little info we have, I'd also say IVR /c PVC's; some perfusing and some not as made evident by SpO2 pleth.

As far as the 2nd goes, I would also call that Controlled A-Flutter at 60.  I would not call that 3AVB.  The only AVB I've ever seen that incorporated anything similar to A-Flutter is a High Grade Block which is even lower in the heart with an intrinsic rate of around 15bpm.  And the complexes are very wide.  It has been my experience and training that if they have a pulse, the won't have much of a BP.


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## VFlutter (Nov 24, 2012)

I totally understand it looks like A Flutter but by definition if the atrial rate is over 400 bpm then it is A Fib, which in that strip it is. Just like if the atrial rate was under 250bpm it would be Atrial Tach. "Regularized A Fib" with a QRS resembling an escape rhythm is suspect for a 3rd degree AVB.


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## Merck (Nov 24, 2012)

Well I have to respectfully disagree.  The second strip is likely an A Flutter.  Leads V1 and V2 show what morphologically appear to be pretty clear flutter waves with a rate of perhaps slightly over 300.  V1 an V2 are probably the best views for the atria and provide the most reasonable interpretation.  And while I'm sure that is a fine website for ECG interpretation I just have to disagree.  Type 1 atrial flutter for sure.


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## 46Young (Nov 24, 2012)

zmedic said:


> Also the QRS is getting pretty wide. Maybe it's PVCs or a ventricular rhythm, but I would worry about things that widen the QRS like TCA overdose or hyperkalemia. It's getting a bit sine wavey.
> 
> But the big thing is if you are going to look at a rhythm strip you should have 3 leads, and a longer strip, like 6-10 seconds worth, or a QRS. One lead is basically "is this Vtach/Vfib?"



I was thinking hyperkalemia myself. Take a look at these images:

http://images.google.com/search?num....epsugrpq2..0.0...1.1.TqtehK7Ok3c&safe=active

Like Bob Page says, "In lead II you got no clue!"


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## bigbaldguy (Nov 26, 2012)

Follow up from my instructor on posted strip. Names removed. Second opinion from two experienced medics with advanced training in EKG interp and an MD. 

Ok gang if you are still following this post I spoke with Dr. Xxxx, xxxx and future Cardiologist Xxxx xxxxx And we concur that this patient is screwed!! The rhythm does not match any rhythm definition exactly. So the possibilities exist that it is  a Block of some sorts, Afib with bigeminy, a funky Ventricular pacemaker and lastly an Acc. IVR. The take home point is treat your patient, the rate and the blood pressures.


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## Christopher (Nov 26, 2012)

Looks like a cycle length of 880 ms or 68 bpm without the "FLB's", a cycle length of 1360 ms or 44 bpm with the "FLB's in between", and a pulse oximetry signal latency (QRS-nadir to pulse oximetry nadir) of 1440 ms. 





Need a 12-Lead to ensure the FLB's are actually....beats


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## bigbaldguy (Nov 27, 2012)

Wow I have no idea whatnthenhell that is but it looks like you put a lot of effort into it so nice job .


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## Christopher (Nov 27, 2012)

bigbaldguy said:


> Wow I have no idea whatnthenhell that is but it looks like you put a lot of effort into it so nice job .



5 minutes in Seashore (Mac's MS Paint) and some multiplication gets you a poor man's ladder diagram


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## MJG (Dec 5, 2012)

bigbaldguy said:


> Follow up from my instructor on posted strip. Names removed. Second opinion from two experienced medics with advanced training in EKG interp and an MD.
> 
> Ok gang if you are still following this post I spoke with Dr. Xxxx, xxxx and future Cardiologist Xxxx xxxxx And we concur that this patient is screwed!! The rhythm does not match any rhythm definition exactly. So the possibilities exist that it is  a Block of some sorts, Afib with bigeminy, a funky Ventricular pacemaker and lastly an Acc. IVR. The take home point is treat your patient, the rate and the blood pressures.



Well, then i haven't been so far off after all 

Do you know this site? http://en.ecgpedia.org/wiki/Main_Page 
Maybe you'll find some extra information there, but I'm afraid you won't get far without a 12-lead ECG.

Cheers!


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