# EKG Question From a Paramedic Student



## mfd229 (Jul 17, 2014)

Dispatched to memory care facility this morning for an 80's year old female complaining of abdominal pain, not alert. Patient was sitting up in a chair upon arrival with slurred speech (normal per staff). Staff states only history is hypertension. Patient was having abdominal pain and staff brought her to the restroom. Patient did not have a bowel movement. Patient brought back out to the lobby where she continued to have abdominal pain. Staff stated they obtained a radial pulse of 36 "4" times. In the ambulance abdomen palpated, no pain or guarding, no masses, however slightly distended. Vitals obtained. 166/90 pulse 60 spo2 88 on room air. O2 brought spo2 up to 96%. EKG performed (see attached). We did not have a medic at this time, this was the rhythm strip I obtained. Upon seeing that I requested a medic. 12 lead performed prior to medics arrival to have ready (Sorry, couldn't get a copy). 12 lead stated complete heart block, however the medic could not see it. Medics opinion was just sinus bradycardia. IV estabished TKO. Patients BP declined to 99/66 in short, 15 minute transport to the hospital. Any ideas on what this could have been?


----------



## FiremanMike (Jul 17, 2014)

Hard to say without more leads, I don't see any p waves in that, but chances are i could find some in at least one of the 12 leads in order to make the call on the block..

I'd be inclined to just try some atropine and forego pacing in this case due to the short transport time and relative stability of the patient.  I'd be ready to pace if anything worsens, though.


----------



## 281mustang (Jul 17, 2014)

Definitely an odd looking ekg... 

I really would like to see a copy of the 12-lead, but with such a short transport time I probably would of just given o2, gotten IV access, and monitored closely while en route.


----------



## mfd229 (Jul 17, 2014)

Hey guys, thanks for the input! I forgot I could go back and reprint 12 leads so that is what I did. Here is our first 12-lead that we obtained.


----------



## 281mustang (Jul 17, 2014)

Obviously some type of block, if pt met criteria you could potentially give atropine to rule out a 3rd degree. 

As a medic student you'll come to learn that we unfortunately deal with these more than the textbook rhythms you see in class.


----------



## blindsideflank (Jul 17, 2014)

I'm wary of a lot of the comments regarding "I wouldn't treat because of the short transport time" That is an interesting statement that opens up a whole new discussion.

Anyways, I see a complete heart block and wouldn't bother with atropine if I felt the need to treat.

Also, who took your pressures? The machine?


----------



## mfd229 (Jul 17, 2014)

Took a manual BP the first time, confirmed it with the monitor. From there on pressures came off the monitor.


----------



## Akulahawk (Jul 17, 2014)

281mustang said:


> Obviously some type of block, if pt met criteria you could potentially give atropine to rule out a 3rd degree.
> 
> As a medic student you'll come to learn that we unfortunately deal with these more than the textbook rhythms you see in class.


Look at leads V1-4. Unless I'm not seeing things right, there be P waves without QRS complexes there... The 3 lead strip has no P waves at all and the QRS complexes are irregular. Could be A-Fib or really could be a complete heart block. I'm leaning toward the latter.


----------



## chaz90 (Jul 17, 2014)

^Yep. Regular p-waves visible in V1-V4 without QRS. Slow and wide complex to boot? 3rd Degree Block.


----------



## Angel (Jul 17, 2014)

281mustang said:


> Obviously some type of block, if pt met criteria you could potentially give atropine to rule out a 3rd degree.
> 
> As a medic student you'll come to learn that we unfortunately deal with these more than the textbook rhythms you see in class.



right? some stuff makes me scratch my head and i feel 'dumb' for not knowing it, but second opinions are always welcome, especially on obscure cases. 




blindsideflank said:


> I'm wary of a lot of the comments regarding "I wouldn't treat because of the short transport time" That is an interesting statement that opens up a whole new discussion.
> 
> Anyways, I see a complete heart block and wouldn't bother with atropine if I felt the need to treat.
> 
> Also, who took your pressures? The machine?



not sure if your protocols are different, but for us atropine is contraindicated for high degree blocks (an acute MI), so if the patient was 'symptomatic' wed go straight to pacing as well.

what i find interesting is how important it is to get multiple views, because lead 3 (on lp15 our default is 2 and 3) you cant see much.


----------



## blindsideflank (Jul 18, 2014)

You ever use Lewis leads/S5?

And we are fortunate that we don't have protocols but pacing is the go to for me in this rhythm


----------



## mfd229 (Jul 18, 2014)

blindsideflank said:


> You ever use Lewis leads/S5?
> 
> And we are fortunate that we don't have protocols but pacing is the go to for me in this rhythm



We don't. Not sure what those are.


----------



## Angel (Jul 18, 2014)

i havent heard of it either but this is what i found. (i know not a super reputable source but here it is)

http://en.wikipedia.org/wiki/Lewis_lead

and


----------



## Akulahawk (Jul 18, 2014)

I learned of the Lewis Lead many years ago... and that setup pretty much right, for use with standard 3 lead monitors. Another setup that is used is this: 






This lead is very good at seeing atrial activity. If it's present in the Lewis Lead, it will be very, very prominent. I first learned about this lead back in Paramedic School. For various reasons, I like MCL1 for monitoring, but that lead won't show P waves anywhere near as prominently as the Lewis Lead does. 

In short, if you _need_ to see if there are P waves, think Lewis Lead!


----------



## Bearamedic (Jul 19, 2014)

Things i see:
the axis deviation, the pwaves without qrs, the qrs without a p wave, the slightly wide qrs, deep swave in III, the avl positive vs the avf negative deflections. 

My conclusion:
3rd degree (junctional escape focus) and left anterior fasicular block




I would have liked to have more complexes though.


----------



## Christopher (Jul 21, 2014)

mfd229 said:


> Any ideas on what this could have been?



Between the 3-Lead and 12-Lead it appears that there is a high degree AV block present, but not necessarily complete. The variable R-R intervals on the 3-Lead shows that occasional capture is present. The P-P intervals are roughly 50 bpm, so we'll go with:

Sinus bradycardia, high degree AV-Block, with an escape perhaps out of the right bundle branch? Quite the slow V-rate.


----------



## mfd229 (Jul 21, 2014)

Based on the EKG, would that warrant transport to a cardiac specialty hospital or is any hospital capable of treating heart blocks?


----------



## Christopher (Jul 21, 2014)

mfd229 said:


> Based on the EKG, would that warrant transport to a cardiac specialty hospital or is any hospital capable of treating heart blocks?



It depends on your area hospitals' setup. I wouldn't take the patient to a community hospital for certain 

It would make sense that any hospital with an emergent cath lab could handle this patient as they would likely do pacemakers as well...but you never know!


----------



## Carlos Danger (Jul 21, 2014)

Pretty much anyplace can float a temporary pacer.....but I would agree that a patient like this should go to a cardiac specialty center, if the difference in transport time isn't too long. That type of thing would ideally be addressed in your destination protocols.


----------



## NPO (Jul 27, 2014)

mfd229 said:


> Took a manual BP the first time, confirmed it with the monitor. From there on pressures came off the monitor.



To me that's backwards. I'll do an automated one and a manual to confirm the machine. I don't trust them.


----------



## MrJones (Jul 27, 2014)

NPO said:


> To me that's backwards. I'll do an automated one and a manual to confirm the machine. I don't trust them.



My practice is to always get the first pressure and pulse manually. For one, I don't always tote the monitor into the house, but I always have my 'scope, cuff and watch. As well, feeling and listening for myself tells me things about the patient that the monitor/auto-cuff doesn't. And, if you think about it, it also forces you to slow down and pay attention to the patient, something that can be important in the first few moments of a contact.


----------



## NPO (Jul 27, 2014)

MrJones said:


> My practice is to always get the first pressure and pulse manually. For one, I don't always tote the monitor into the house, but I always have my 'scope, cuff and watch. As well, feeling and listening for myself tells me things about the patient that the monitor/auto-cuff doesn't. And, if you think about it, it also forces you to slow down and pay attention to the patient, something that can be important in the first few moments of a contact.



Agree on all points. Except on not taking the monitor in. Its policy for us. I'm quick to dismiss a NIBP and pull out a manual if something smells fishy, or just go straight for manual if I have a feeling it might be high, low, or hard for the machine to get from any reason.


----------



## MedicJon88 (Jul 31, 2014)

hey, so i'm trying to break the strips down to analyse it like I would at my work. using the 12 lead. 
Slightly Irregular in Rate
PR- un-measureable
QRS looks like its at .12 
Rate is in the 50s
looks like the P waves are not correlated with the QRS

my interpretation 3rd degree heart block with Junctional rhythm


----------



## tpchristifulli (Sep 8, 2014)

Figure out why her sp02 was 88% .... Is she normally on 02? ABC's.


----------



## Jason (Sep 9, 2014)

I'm leaning towards 3rd Degree HB.  And if the Pt is stable, then supportive measures, O2, IV, Monitor. I would not use atropine in this rhythm.  If the Pt became symptomatic, I would pace.  Atropine is not ideal for 3rd Degree, because all you really get is a faster 3rd Degree and potentially make it worse.


----------



## Handsome Robb (Sep 9, 2014)

MedicJon88 said:


> my interpretation 3rd degree heart block with Junctional rhythm



Never heard a CHB analyzed that way. With that said the morphology and duration indicates a junctional focus for the QRS rather than the normal "wide and ugly" ventricular foci.

I agree that atropine isn't a diagnostic tool as it could worsen the patients condition.


----------



## Akulahawk (Sep 10, 2014)

I went back through the strips and that's a good way to describe what's going on. What I saw was: 3rd Degree block, junctional rhythm, and probably LBBB... 

I wouldn't give atropine as it's not likely to improve anything... and if the patient's condition worsens, fire up the pacer and provide a nice ride.


----------



## Brandon O (Sep 10, 2014)

Handsome Robb said:


> Never heard a CHB analyzed that way.



Which part?


----------



## Christopher (Sep 10, 2014)

Handsome Robb said:


> Never heard a CHB analyzed that way.



Perhaps it would be better stated as "sinus rhythm, complete heart block, and a junctional escape with LBBB."

Although, I disagree that CHB is present due to evidence of variable R-R intervals on the 3-Lead. This indicates some conduction is possible.


----------



## Mantis Toboggan (Dec 29, 2014)

Jason said:


> I'm leaning towards 3rd Degree HB.  And if the Pt is stable, then supportive measures, O2, IV, Monitor. I would not use atropine in this rhythm.  If the Pt became symptomatic, I would pace.  Atropine is not ideal for 3rd Degree, because all you really get is a faster 3rd Degree and potentially make it worse.



Atropine will not affect the rate in a 3rd degree block, for better or worse.  In the case of a CHB, the automaticity foci in the ventricles have assumed the role as pacemaker due to a conduction failure of the AV node. The SA and AV nodes are the only parts of the heart with parasympathetic innervation—via the vagus nerve. Atropine 'speeds up' the heart by inhibiting the action of acetylcholine, decreasing parasympathetic tone. The ventricular rate of a 3rd degree block can be quickened by sympathomimetics like epi (not recommended) or through TDP.  The slow ventricular response is linked to the intrinsic firing rate of the automaticity foci (20-40) and not by parasympathetic tone (which is absent—distal the AV node).


----------



## Christopher (Dec 29, 2014)

Mantis Toboggan said:


> Atropine will not affect the rate in a 3rd degree block, for better or worse.


Not quite true. It will not affect a ventricular escape rhythm. If the AVB is vagally mediated, then atropine may improve conduction (common in IWMI). If the escape is junctional, then atropine may improve the rate.



Mantis Toboggan said:


> In the case of a CHB, the automaticity foci in the ventricles have assumed the role as pacemaker due to a conduction failure of the AV node. The SA and AV nodes are the only parts of the heart with parasympathetic innervation—via the vagus nerve. Atropine 'speeds up' the heart by inhibiting the action of acetylcholine, decreasing parasympathetic tone. The ventricular rate of a 3rd degree block can be quickened by sympathomimetics like epi (not recommended) or through TDP.  The slow ventricular response is linked to the intrinsic firing rate of the automaticity foci (20-40) and not by parasympathetic tone (which is absent—distal the AV node).


This is all "true", assuming a distal block in the AVN and a ventricular escape.


----------

