# PAC?  Short runs of A-flutter?



## korvus (May 25, 2011)

I saw this ECG from a patient the other day who complained of 7/10 chest pain originally, but claimed he was down to 1-1.5/10 by the time we arrived.  He only went in the ambulance because his wife insisted.  







It looks to me like perhaps non-conducting PACs?  Perhaps one-ventricular-beat-wide runs of A-flutter?  I find it odd mostly because these always showed up right between the T and P waves, which made me think the ventricular activity had something to do with it (not just something odd going on in the atria).  Based on the morphology across the leads, it's obvious something different is going on for that middle bump versus normal P/T waves.  

I'll note the patient could feel when these happened.  I guess my best analysis would be PACs and the atria only fired at those times because any other time, whenever they tried to fire, they were in a refractory state.  But I'd love to hear what others have to say.

I'd also be interested in what this means for the patient.  We'd see 2-3 of these, separated by a few normal beats, every minute or two.  So they were frequent, but he seemed hemodynamically stable...  

Thanks!


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## Aidey (May 25, 2011)

You're over thinking this. There is nothing odd about it showing up between the T wave and P wave. Unless you are nearing R on T beats most of your individual ectopic beats are going to fall between the normal QRS complexes. Since the patient can feel them that is a pretty good indication that they are conducting. 

To break it down. 

There are no preceding P waves, nor do there appear to be P waves buried in the T waves. Evidenced by the fact all the normal T waves look the same. 

They are not wide enough to be PVCs.

Which leaves PJCs 

In the absence of any information about the patient they don't really mean anything.


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## mgr22 (May 25, 2011)

I'd say interpolated PVCs.


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## MSDeltaFlt (May 25, 2011)

korvus said:


> I saw this ECG from a patient the other day who complained of 7/10 chest pain originally, but claimed he was down to 1-1.5/10 by the time we arrived.  He only went in the ambulance because his wife insisted.
> 
> 
> 
> ...



Exactly.  You guys are over thinking this without nearly enough information. You need a 12 Lead.  You're trying to diagnose PAC, PJC, PVC, not even considering aberrant conducted beats (which are as benign as PAC's by the way) without looking at the entire heart.

Get a copy of the 12 lead, adhear to HIPAA, then repost if at all possible.  Probably isn't now anyway.  Chart's probably in MR.


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## mycrofft (May 25, 2011)

*Look at all the leads showing, don't focus on the red circles.*

I vote for IPJC, if I'm paid enoughB)


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## korvus (May 25, 2011)

Thanks for the input everyone!  It's possible I could get a copy of the 12-lead I assume the hospital did, but this is a hospital that isn't great about giving us info on our patients, so I'm not holding my breath.  All we can do on the ambulance (and this required us to fight the state) is a 5-lead.  While I would definately would like to know what the "real" problem was, I guess my main focus is a little different.

I have a patient who had chest pain, but claims it is mostly gone.  He is feeling strange beats that show up as in the ECG.  Since I won't get a 12-lead until after this patient is no longer in my care, what does this mean to me?  If I can't say for sure what it is, what are the likely options, and do any of those concern me over the next two hours? (long transports where I work...)  

I've only been working as a real EMT-I/85 (on an ambulance) in the past six months, and it's only been in the last month or two that I've found myself in charge of patients who aren't just babysitting jobs.  I know the easy stuff (say, VF/VT and what to do about them), but I'm trying to start developing my skills for the situations that are less clear.

For those who want a little more information, the patient was older (60s), claimed a history of intermittent A-fib, and was on a statin, a HTN med, a beta blocker, and daily ASA.  You can see his vitals on the strip -- pretty normal but lowish BP and HR, which could be attributed to his meds.  

Since this started with a chest pain complaint, I want to know if what I'm seeing on the monitor gives me a hint of either what happened or where this is going.  Keeping in mind that I was 2 hours from a 12-lead, does this tell me anything, or does it just give me something to mention to the ER for them to follow up on?


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