bigbaldguy
Former medic seven years 911 service in houston
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What do you think.
EKG interp
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What do you think.
VFlutter
Flight Nurse
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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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Without a 12 I'd call it IVR with PVCs.
Just my .02
Just my .02
VFlutter
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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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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?
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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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
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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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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.
VFlutter
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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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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.
FWIW I'd almost be inclined to call that A-flutter but then again in other leads it's definitely A-fib.
TomB
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What do you think.
The SpO2 waveform does not look contemporaneous with the ECG which seems odd.
VFlutter
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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
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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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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.
OP
OP
bigbaldguy
Former medic seven years 911 service in houston
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Thanks for the input all. Afraid I don't have any info on patient presentation just the strip.
Christopher
Forum Deputy Chief
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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.
Shishkabob
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The squigglies aren't squiggling right.
VFlutter
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Better than not squiggling at all...
Merck
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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.
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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