# EKG Interpretation (WPW, delta waves?) 56k... meh.



## jedirye (Apr 23, 2008)

Hello all,
I have finally acquired a scanner so I would like to actually have some of these strips interpreted. Unfortunately, for a lot of them I will only have the strips due to the delay it took me to upload them; I have lost the "story" that went along with them. Some may be obvious, some may not.

First up is this strip. Now I've talked to a lot of people about this and given the subject, the one remarkable thing that caught my eye was the possible delta waves. However, I may be eager and just reaching here (and I'm sure I am).


Story: From what I remember, this strip involved an approximately 50-60 year old female pt with chief complaint of chest pain. All of the other details unforunately have escaped me at this point. However, enroute my partner called to get orders for Cardizem (approximately 17mgs total) given the sustained HR of about 150BPM. My partner pushed about 2.5mgs, and then proceeded to push another 2.5mgs when the pt screamed in agony, clutched her chest, and my partner says the monitor went "crazy". Apparently it happend so quickly she did not have time to hit print. Regardless, pt's HR dropped to a sustained 70-80BPM and all went well. Once again, I wish I could have recalled more (OPQRST of complaint, hx, meds, etc.) but unfortuantely I just do not recall. Also worth noting, a 12-lead was done on scene by a supervisor on their monitor, hence the reason when I printed a code summary it was not included as it was not done on our monitor. Nothing remarkable to supervisor/my partner, however. So, what do you guys think? Appreciate any insight, I am always eager to learn as much as I can especially something new!


Strips:























Thanks!

-rye


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## Onceamedic (Apr 23, 2008)

Did you run a 12 lead?
Looks like the patient was in afib 2:1 conduction, converted with cardiazem, then into controlled afib...
Was there a paramedic on board?  I tend to think there must have been because of the drug administration.  Was the afib new onset?  Did you get medical control to cardiovert?  I don't understand.
OK - saw that a 12 lead was run by someone else.  Who pushed the drug?


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## mikie (Apr 23, 2008)

Just out of curiosity, what monitor are you using?  

And just a friendly tip: you may want to shrink those strips (looked like you used photobucket, I believe you can edit the size on their site- it took a while to load and I have to scroll horizontal pretty far to see it all (but it could just be me, so if so- forget it!)

Thanks!

(thanks for posting the strip too, I like when people post strips, makes for interesting discussions! (I can't really interpret EKG, only a basic and have had no formal training- but great place to learn)


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## firemedic31075 (Apr 23, 2008)

> Did you run a 12 lead?
> Looks like the patient was in afib 2:1 conduction, converted with cardiazem, then into controlled afib...
> Was there a paramedic on board? I tend to think there must have been because of the drug administration. Was the afib new onset? Did you get medical control to cardiovert? I don't understand.
> OK - saw that a 12 lead was run by someone else. Who pushed the drug?



A. Fib 2:1 conduction? I think you may be confused with A. Flutter. But this strip is neither of those. I think the Fib you think you see is just artifact...remember A. Fib is irregularly irregular so the complexes would not be spaced evenly apart. This looks like sinus tach. borderline SVT with a 1 degree block. Im assuming the attending medic administered adenocard without success then used cardizem with successful conversion to what looks like a sinus rythm with 1st degree block. As for delta waves I dont see any but like always I could be wrong. And cardioversion? What dont you understand? It is definitly not indicated here due to what sounds like a stable patient. Only thing I dont like is that b/p at 20:41 74/49 after the cardizem hopefully her pressure came back up.



> Just out of curiosity, what monitor are you using?



Lifepak 12


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## Onceamedic (Apr 23, 2008)

You are right..  I was confused - afib is always irregular and I certainly don't see flutter waves.  ECGs is my weak spot for sure.
Thanks for setting me straight


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## jedirye (Apr 23, 2008)

Shoot, I just tried to resize the first image but it looked pathetic.

<EDIT BY CL - Original strip relocated to 1st post at User Request>


Anyway, yeah her BP dropped but she was given Cardizem so a fluid bolus fixed her right up. Other than that, no adenosine wasn't tried first and after posting that I was pondering that myself. I don't recall exactly the events or reasons why, to be honest with you.

And I keep thinking delta waves because there does seem to be a subtle curvature of the r wave and even in later strips it almost looks partly broken like a bundle branch block even though the QRS isn't nearly wide enough. No?? Also, I realize that with WPW syndrome the PRI would be shortened due to the use of the accessory pathway (Kent), but a combination of possibly artifact and my own lack of experience/interpretation, it's just hard for me to distinquish the p waves.............

-rye


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## MSDeltaFlt (Apr 23, 2008)

OK, first off, there was no 12 Lead posted (you explained why so no biggie) which means you cannot say for sure what the rhythm is.  You needed ALL 12 leads to truely figure out what's going on.  Lead II is correct in rhythm interpretation 34% of the time.  Which means it wrong *66%* of the time.  You can't even diagnose asystole without another lead beside it.  I'm hoping your pt was definitely symptomatic for use of Cardiazem on a rhythm that was technically not 150.  She felt better afterwards so no obvious iatragenic effects.

Can't say for sure on anything because not enough information.  Sorry, bro.


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## backinboston (Apr 23, 2008)

If you really thought you saw delta waves... which just for the record are not there... you should have been a lot more cautious about using adenosine or cardizem.

If WPW is present the only options I have on my truck are amiodarone or cardioversion. By blocking/slowing down the AV node conduction you allow the existing extra bundle to conduct at an unobstructed and uncontrollable pace.

-s


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## jedirye (Apr 23, 2008)

backinboston said:


> If you really thought you saw delta waves... which just for the record are not there... you should have been a lot more cautious about using adenosine or cardizem.



Exactly my sentiment! From a 12-lead class I took I did recall you had to be *extremely *careful when administering Cardizem.

I was only acting as the EMT-B on this truck of medic and EMT. I didn't get the whole strip until after the call, and after closely examining it, I thought, "Hey, these kind of look like delta waves." As much as I like to "play the medic", I realize I've got a role to do and can't be acting as a third in a clinical when I know I've got to get stuff done for my partner.

For those of you so quick to disregard the D waves, would you care to explain what we are both looking at. Obviously if you guys already know that I am suspecting those waves, is there another explanation for the QRS complexes to be shaped the way they are? They just have such a discernable shape though. Also, from looking on the internet, I thought it was only more of a confirmation of them given these pics as examples of delta waves:











Thanks,

-rye


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## backinboston (Apr 23, 2008)

Not to disreguard your last post but...

If you grab a rhythm strip and bring it into a room with a group of paramedics/cardiologists/doctors/or even avid ekg interpetors...

you will hear an equal amount of interpretations....

Each will find something different, some small abarrency and want to treat it differently...

Its all in the eye of the beholder.... obviously there are those cases where its obviously something but in the end its treat the pt not the monitor and base your interpretations off experience and in the end "the 5 rules" to each dysrhythmia

good luck pal... your interest will really help you with your career


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## firemedic31075 (Apr 24, 2008)

> Lead II is correct in rhythm interpretation 34% of the time. Which means it wrong 66% of the time.




Huh? dont quite understand this.


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## Ridryder911 (Apr 25, 2008)

Kaisu said:


> You are right..  I was confused - afib is always irregular and I certainly don't see flutter waves.  ECGs is my weak spot for sure.
> Thanks for setting me straight



Couple of things, interperting WPW without 12 lead and possible history of previous WPW, is asking for trouble. Ever seen Cardizem in WPW?.....

Sorry, A-fib is *NOT* always regular irregular, in fact not really uncommon for A-fib to be regular! Also, one can have A-fib/third degree... read some advance cardiology....

R/r 911


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## MSDeltaFlt (Apr 25, 2008)

firemedic31075 said:


> Huh? dont quite understand this.



When diagnosing the origination of the impulse, especially with ventricular based rhythms, Lead II has an accuracy rate of around 34%.  In other words it's wrong 66% of the time.

To officially diagnose a rhythm, you need to look at the 12 Lead taking in EVERY lead.


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## MSDeltaFlt (Apr 25, 2008)

Ridryder911 said:


> Couple of things, interperting WPW without 12 lead and possible history of previous WPW, is asking for trouble. Ever seen Cardizem in WPW?.....
> 
> Sorry, A-fib is *NOT* always regular irregular, in fact not really uncommon for A-fib to be regular! Also, one can have A-fib/third degree... read some advance cardiology....
> 
> R/r 911



Rid,

The ECG course I took that covered that A-fib/third degree rhythm called it a "High Grade" Block.  I've actually seen it on a pt.  The isoelectric line was A-Flutter with a very wide and bizarre VR ~ 10 bpm.  It's an impressive thing to witness.


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## Ridryder911 (Apr 25, 2008)

Yes, it is impressive and with more patients that can tolerate diseased hearts, we will see more bizarre arrhythmias. 

I want to point out to be cautious on learning ECG's as absolute, i.e. A-Fib is always regularly irregular, etc.. I was taught and then expanded my ECG skills through Marriott's Advanced ECG interpretation school. In actuality is not a "heart block" rather an A-V dissociation (it is doing its job too well). The reason I shudder when I hear the term "heart block"; and those that presume 3'rd degree is the worse block; when in reality 2'nd degree type II has a higher mortality rate (precursor to lethal AMI's). 

Yes, learning ECG's is overwhelming, and one will be seeing "little boxes" for a while after taking an ECG course. The only way to improve ECG's interpretation skills is read ECG's and I do mean several hundred to begin with. I know I am more rusty than I was working in CCU and seeing several cardiac patients and monitoring telemetries. It is one of those skills that has to be continuously practiced upon . 

R/r 911


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## MSDeltaFlt (Apr 25, 2008)

"It is one of those skills that has to be continuously practiced upon ."

You ain't kiddin'.  Kinda like a muscle.  You don't use it, you lose it.


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## jedirye (Apr 25, 2008)

I'm really kicking myself now for not asking my supervisor to get a code summary for me that I could pick up later, or for her to even interoffice it.

Regardless, I've acquired more of the story after talking to my partner who even admits that remembering all the details is even a bit rusty for her. Pt's age as stated, chest pain had a gradual onset with the start approximately four days prior to our arrival. Pt was given a fluid bolus to rule out Sinus Tach, and treated per protocol for chest pain up to and including 325mg ASA, and I believe she had about two shots of nitro, all to no relief. In our protocols Adenocard is not given until a rate of 160bpm (symptomatic), but her rate wasn't high enough for Cardizem either, hence the orders. Oh well, thought I would share...

-rye


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## Ridryder911 (Apr 25, 2008)

jedirye said:


> I'm really kicking myself now for not asking my supervisor to get a code summary for me that I could pick up later, or for her to even interoffice it.
> 
> Regardless, I've acquired more of the story after talking to my partner who even admits that remembering all the details is even a bit rusty for her. Pt's age as stated, chest pain had a gradual onset with the start approximately four days prior to our arrival. Pt was given a fluid bolus to rule out Sinus Tach, and treated per protocol for chest pain up to and including 325mg ASA, and I believe she had about two shots of nitro, all to no relief. In our protocols Adenocard is not given until a rate of 160bpm (symptomatic), but her rate wasn't high enough for Cardizem either, hence the orders. Oh well, thought I would share...
> 
> -rye



It is easy to armchair quaterback. Especially ECG's, and attempting to interpert while going down the road and multi-tasking.. 

Thanks for sharing...

R/r 911


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## firemedic31075 (Apr 26, 2008)

> Sorry, A-fib is NOT always regular irregular, in fact not really uncommon for A-fib to be regular! Also, one can have A-fib/third degree... read some advance cardiology....



If you could find an example of A-Fib/third degree block and post it I would like to see it. I tried searching myself but couldn't find anything. I would imagine the only time A. Fib would be regular is with an atrial /ventricular disassociation because the impulse is blocked it would be a regular ventricular rhythm. But other than special circumstances like that when else would A. Fib be regular? I'm a paramedic not a cardiologist so I'm probably not going to take an advanced cardiology class. 


So this is a wrong definition?

"Atrial fibrillation occurs when the atria depolarize repeatedly and in an irregular uncontrolled manner usually at at atrial rate greater than 350 beats per minute. As a result, there is no concerted contraction of the atria. No P-waves are observed in the EKG due to the chaotic atrial depolarization. The chaotic atrial depolarization waves penetrate the AV node in an irregular manner, resulting in irregular ventricular contractions. The QRS complexes have normal shape, due to normal ventricular conduction. However the RR intervals vary from beat to beat."


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## Ridryder911 (Apr 26, 2008)

firemedic31075 said:


> If you could find an example of A-Fib/third degree block and post it I would like to see it. I tried searching myself but couldn't find anything. I would imagine the only time A. Fib would be regular is with an atrial /ventricular disassociation because the impulse is blocked it would be a regular ventricular rhythm. But other than special circumstances like that when else would A. Fib be regular? I'm a paramedic not a cardiologist so I'm probably not going to take an advanced cardiology class.
> 
> 
> So this is a wrong definition?
> ...



I too am not a Cardiologist, but I do want to know how to read ECG's thoroughly enough to not to inadequately treat and to do my job well. There is a far difference from taking even an advance ECG class and being a Cardiologist.. 

Actually the definition is only partly right and very simplistic. No, there is never "P" waves rather they are "F" waves and due to the bundle/nodal is doing its job there *may* be an irregular pattern that comes usually comes from Bauchman's bundle. There again is no real "block" rather the AV is performing its job to slow the rate from the atrium, usually the foci is effected by hypoxia, electrolytes, etc. This of courses causes more problems, such as deterioration of the Os Cardia (yes, the bone of the heart) which can also cause deterioration of the myelinated sheath of the electrical system, which is prevalent in such conditions as AV Dissociation = Heart Block.


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## MSDeltaFlt (Apr 26, 2008)

http://www.ecglibrary.com/af_chb.html

I believe this is what Rid and I are talking about.  I've seen them with flutter waves.  There can also be A-Fib pattern as well.


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## Ridryder911 (Apr 27, 2008)

Thanks, those are hard to come by... or they are usually misdiagnosed. The problem is that because they are in A-fib and have a  A/V disassociation, just placing a ventricular pacer in will not correct the rhythm, A/V sequential pacer may surpass to ablate the A-fib. 

R/r 911


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## mikeylikesit (Jun 4, 2008)

well since the P waves are stacked with he t wave but maintain a constant interval i am going to say that on the first strip you have either an MAT or a WAR. on the last strip they look like a ventricular escape beat or a fib.


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## mikeylikesit (Jun 4, 2008)

and just for the record this is V flutter.





and this is A flutter.


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## Ridryder911 (Jun 4, 2008)

V-flutter which by the way looks very similar to CPR artifact, is actually sometimes called course v-fib as well. It has to do with if the patient is perfusing or not. Most likely not.

Again, emphasis should be upon treating the patient not the monitor, as well since all morphologies of v-tach (pulseless) is really v-fib. 

R/r 911


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## mikeylikesit (Jun 4, 2008)

yes i agree, it is very hard for me or anyone i know to distinguish the two, that is why like you said we treat the patient first and not the monitor.


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