88 y/o female with palpitations

zzyzx

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Here's a tricky ECG for you. To be honest, I was really annoyed the other night because I could not figure it out until an ED doc explained it.

88 y/o female c/o palpitations, otherwise asymptomatic. All her vital signs are stable. She says this has happened to her before and that it is "my A fib acting up."

This is what you first see on the monitor (see image): a wide-complex tachycardia, regular and with no variation of the heart rate of 155.

(12 lead to follow later).
 

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MonkeyArrow

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While the rate technically qualifies it as an SVT, it certainly does not look like your normal one. The strip almost looks like R-on-T phenomenon. I eagerly await more info and the 12 lead.
 

EMT11KDL

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I am waiting patiently for the 12 lead with monkey. but first thing I would do seeing that is check my leads/wires/connections because that would not be what I would be expecting to see from the short description you gave.
 

Gurby

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Well, it's not her AFib acting up... (or is it?)

Garcia says that when you see a rate of exactly 150, consider AFlutter with 2:1 conduction. Given history of AFib, she might be on calcium channel blockers or have AV node pathology that could maybe help cause this... Wide complex due to aberrant conduction maybe - bundle branch or hemiblock?

It would be interesting to know her relevant cardiac history/meds, see old EKG's, etc.
 

zzyzx

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You will have to rotate the file after you open it. I'm not sure why it keeps getting uploaded like this.
 

Gurby

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I think I stand by my first guess. The P waves look a bit sawtoothy, and the PR interval is so short at times that it feels like there could be another P wave buried in the previous QRS that is the one that actually gets through. Or not.
 

MackTheKnife

BSN, RN-BC, NREMT, EMT-P, TCRN
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Rate is 150 and concur with aberrant conduction.
 

zzyzx

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You can rotate the image after you upload it. Sorry, don't know why it up loads rotated like that.
 

Gurby

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Still standing by my previous guess of AFlutter with 2:1 conduction. Now that you've given her a Ca channel blocker you're further messing with the AV node, causing it to flip around to 2:1 or 3:1.

Kind of concerned about v1 and v2 though. It could either be rate-induced ischemia, or maybe ischemia happened first and affected the AV node, causing this arrhythmia?
 

Aprz

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Damn your sideways ekg's.

Why cardizem?
Asymptomatic. Does not compute.
88 y/o female c/o palpitations, otherwise asymptomatic. All her vital signs are stable. She says this has happened to her before and that it is "my A fib acting up."
She was symptomatic. I kinda find it confusing when people say the patient is complaining of _____, otherwise asymptomatic. People usually miss the part before the asymptomatic part even when the report is verbal.

I agree with what others have said about it being atrial flutter. It looks like 2:1 atrial flutter prior to cardizem administration and 4:1 atrial flutter post cardizem administration. The rate of 150 prior to cardizem and 75 with visible flutter waves in the inferior leads II, III, and aVF supports this. Fibrillation can look like p-waves or flutter waves, but I measured atrial activity / flutter waves rate to be 300 supporting atrial flutter. Atrial fibrillation can look regular at a high rate, but this is obviously regular even at a slow rate. Atrial fibrillation can become regular and slow with digoxin.
 
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zzyzx

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Yup, A flutter with 2:1 conduction. Nice job guys! For a long while after the CCB, she bounced around between AF, AF 2:1, and AF 4:1, until settling down to AF at a normal rate. She was given PO diltiazem as well.
 

teedubbyaw

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Are palpitations a reasonable symptom to push cardizem w/ a rate of 150? Meh. Is a rate of 150 high for an 88 y/o? Meh. Does she have a prescription for a CCB? Probably. Let a cardiologist dig deeper.
 
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