EKG no one can figure out.

[Aidey]

These EKGs are from a patient of mine. I was unable to follow up on her, so I do not know what the cardiologist called it. However, no paramedic or ED Doc has been able to conclusively call it anything.

~350lb, 63 yo female, called for shortness of breath at a private residence.

HPI: The patient reports that she has been having increased SOB for the last few days. She was recently (4-5 days ago) diagnosed with a UTI and is taking an unknown oral antibiotic for it. She can not recall having SOB to this degree before.

ROS: (+) Feeling feverish, temp of 100.6 today. Denies lightheadedness, dizziness, headache, vision disturbances. Denies cough, productive or not. Denies chest pain. (+) SOB, especially on exertion. Denies nausea, vomiting or diarrhea. (+) Increasing pedal edema over the last month.

PMHx: HTN, hyperlipidema, diabetes, A-Fib, LBBB, COPD, Asthma, CHF. Kidney transplant 10 years ago, one failed transplant before that. Reports that all recent labs have shown her kidney function is fine. She is scheduled for a pacemaker in a week because of a "slow heart rate". Pt reports that over the last month she has had several episodes of her heart rate being as slow as 36 bpm. She does not know the specific diagnosis. None of the potential dxs sounded familiar to her.

Allergies: Morphine, CDN, PCN, Sulfa

Meds: Duonebs q4hrs, Albuterol PRN, Advair, Lisinopril, Levothyroxine, Glipizide, Metformin, Novolog, Lantus, Simvastatin, ASA, and an antirejection med I can't remember the name of.

Vitals: P - 60. R - 28-34, labored. Bp - 160/88. Lungs - Diminished, but clear. Room SpO2 - 80%. SpO2 on 10lpm 97%. Co2 - 40 mm/hg. CBG - 216 mg/dl.

It is very important to look at both.

Here is the 12 lead

And here is the 3 lead

 

[mycrofft]

Litella maneuver this comment

"Never Mind"

 

[luke_31]

Looks like a sinus rhythm with a first degree heart block and p-mitrale. R wave progression is abnormal. Normal Axis deviation.

Judging by the pt's history I would say she has a very sick heart and would be cautious with providing treatments that would make the heart work harder as it already is struggling.

 

[Aidey]

How do you explain all those p waves without a corresponding QRS? Or the P waves buried in the preceding T waves? Or the change in QRS morphology (negative deflection to positive deflection)?

 

[STXmedic]

My shot:

2nd degree Type 2 with a LBBB, LAE, and Anterior-Lateral MI

Edit: Though V1 suggests RAE as well...

 

[STXmedic]

Normal axis. Starts off with a mildly normal though slightly delayed R wave progression, but drops off to Q waves, suggesting necrosis

/facepalm.... Maybe if I would read and not jump straight to the 12 lead PCCs at the start of the 3 lead for sure. That's the best I've got

 

[Aidey]

Normal axis. Starts off with a mildly normal though slightly delayed R wave progression, but drops off to Q waves, suggesting necrosis

/facepalm.... Maybe if I would read and not jump straight to the 12 lead PCCs at the start of the 3 lead for sure. That's the best I've got

Yeah, you HAVE to look at the 3 lead, it gives nearly as much info as the 12 lead does. I'm assuming you mean PVCs?

In a 2nd degree, Type II block wouldn't the QRS-T complex end prior to the next P wave starting? If those are PVCs, you also don't often see buried P waves. In both versions of the QRS there are buried P waves in the T waves.

An interesting thing to note is that the P waves march out at ~120 bpm, and the QRS complexes march out ~60 bpm. That makes it a little harder to tell if there is actually an association between the P waves and QRS complexes, or if it is a crazy coincidence that they seem to line up in some way.

Another interesting thing is that when she switched from the positive QRS complexes to the negative complexes there were always 4-5 of the P waves without any QRS complexes before the negative complexes started up.

I tried to get 12 leads of the two different QRS complexes, but I wasn't successful. She went back and forth a number of times.

 

[STXmedic]

Yeah, you HAVE to look at the 3 lead, it gives nearly as much info as the 12 lead does. I'm assuming you mean PVCs?

In a 2nd degree, Type II block wouldn't the QRS-T complex end prior to the next P wave starting? If those are PVCs, you also don't often see buried P waves. In both versions of the QRS there are buried P waves in the T waves.

An interesting thing to note is that the P waves march out at ~120 bpm, and the QRS complexes march out ~60 bpm. That makes it a little harder to tell if there is actually an association between the P waves and QRS complexes, or if it is a crazy coincidence that they seem to line up in some way.

Another interesting thing is that when she switched from the positive QRS complexes to the negative complexes there were always 4-5 of the P waves without any QRS complexes before the negative complexes started up.

I tried to get 12 leads of the two different QRS complexes, but I wasn't successful. She went back and forth a number of times.

I'm sure Tom will correct me if I'm wrong, but the ventricular repolarization won't have any affect on the atrial depolarization. The fact that it's 120:60 really makes me think Type 2 with a 2:1 conduction delay. If the change to negative complexes are preceded by multiple P waves with no QRS, I think her block is progressing to a complete block. The switch to negative deflection complexes (PVCs) would be from the ventricular escape 2/2 the complete heart block. Once the beats start going back through the block at 2:1, the ventricular escape ceases, switching back to positive complexes. A previous 12 lead would be wonderful (obviously not likely for you to have) to see if the Q waves laterally are new or old. If new, could explain the possibly new onset LBBB and intra-nodal block

 

[luke_31]

How do you explain all those p waves without a corresponding QRS? Or the P waves buried in the preceding T waves? Or the change in QRS morphology (negative deflection to positive deflection)?

Not paying close enough attention and a bit tired

 

[sir.shocksalot]

My shot:

2nd degree Type 2 with a LBBB, LAE, and Anterior-Lateral MI

Edit: Though V1 suggests RAE as well...

I would consider a rate dependent block or an escape rhythm also. There is a p wave for every qrs but not a qrs for every p wave. The change in morphology is tough to explain, especially since there are still p waves before complexes.

That said, t wave discordance and elevation in the anterior leads is normal in a LBBB and not indicative of ischemia or infarction.

Very interesting 12 lead, hopefully an expert will jump on here and clear it up for those of us that apply electricity until the rhythm looks recognizable

 

[Aidey]

The LBBB isn't new, she was the one who told me she had it.

I agree that whatever it is, it is heading towards a complete block. Especially with her history of a heart rate intermittently the 30s.

As near as I can tell from some quick research a 2nd degree Type II generally repolarizes normally, meaning there will be a distinct T wave separate from the P wave.

When I scanned the EKGs I made the files huge, so I could blow them up and examine them closely. On the 3 lead the PRI is NOT constant, for either the positive or negative QRS complexes. It is very close, but when you've got it blown up so that each QRS is 3 inches tall it becomes much easier to see.

Edit: If anyone wants those huge files to take a look on their own, or to use in a class send me a PM.

 

[TomB]

Today is my last day of vacation in Northern Michigan and I have to come back home to the grind today. Ugh! Anyone have a suggestion for early onset post-vacation depression???

Anyway, it appears this patient has a very sick heart and a pacemaker with the lower rate limit set to just under 60. The rhythm strip shows 2:1 pacing with intrinsic AV conduction overtaking the paced rhythm. Take a VERY close look at the PR-intervals and R-R intervals to see what I'm talking about. When the patient's own heart rate hits 60 the pacemaker stops pacing.

At first I thought the 12-lead ECG showed 2:1 pacing but I looked at that prior to the rhythm strip. It shows untypable 2:1 block with nonspecific IVCD (LBBB morphology in lead V1 but negative concordance in the precordial leads which is unusual for LBBB -- this is just nitpicking).

The slight concordant ST-elevation in lead III and slight concordant ST-depressioin in aVL would be enough to make me compare to an old ECG if the patient was complaining of any s/s suggestive of ACS.

Cool ECGs!

Now how about those tips for end-of-vacation anxiety?

Tom

 

[Aidey]

She absolutely does not have a pacemaker, but she is scheduled for one very soon.

Edit: Trust me, I asked and looked. The FD had mentioned the pacemaker surgery on scene. When I hooked her up in the amb and saw that I said "So you are scheduled for a new pacemaker next week?" And she said no, she did not have a pacemaker, and has never had one.

 

[TomB]

The rhythm strip speaks for itself but I'm certainly not going to get in an argument over it. Thanks for the interesting case!

 

[Aidey]

Anyway, it appears this patient has a very sick heart and a pacemaker with the lower rate limit set to just under 60. The rhythm strip shows 2:1 pacing with intrinsic AV conduction overtaking the paced rhythm. Take a VERY close look at the PR-intervals and R-R intervals to see what I'm talking about. When the patient's own heart rate hits 60 the pacemaker stops pacing.

At first I thought the 12-lead ECG showed 2:1 pacing but I looked at that prior to the rhythm strip. It shows untypable 2:1 block with nonspecific IVCD (LBBB morphology in lead V1 but negative concordance in the precordial leads which is unusual for LBBB -- this is just nitpicking).

The slight concordant ST-elevation in lead III and slight concordant ST-depressioin in aVL would be enough to make me compare to an old ECG if the patient was complaining of any s/s suggestive of ACS.

Tom

Also, that isn't concordant ST elevation, it is a buried P wave. I thought it was concordant elevation when I first saw it too, but on some of the strips you can see 2 tiny little peaks that match the other P waves.

 

[Aidey]

Even if the patient was such a bad historian she forgot she had a pacemaker, I'm pretty sure her husband or RN daughter would have mentioned it rather than saying she was scheduled for surgery.

If you PM me your e-mail address I can send you the large files so you can take a closer look at them.

I don't want to argue either, I want to know what it is, and I know it is not a pacemaker.

 

[TomB]

Even with the P-wave superimposed on top, the ST-segment should be slightly depressed. If you look very carefully the J-point is elevated about a isoelectric line width above the expected position which is significant because of the very small amplitude of the QRS (rule of proportionality). In the first cardiac cycle the ST-segment appears to be slightly up-sloping. That could be artifactual, but taken together with the little Q-wave in lead III and the unusual (possibly reciprocal) ST-depression in lead aVL it's something to keep an eye on. That's all I'm saying.

 

[MSDeltaFlt]

P's walk out. Complexes walk out. Rate's slow enough, and complexes wide enough. I'm calling it 3° AVB.

 

[Too Old To Work]

Today is my last day of vacation in Northern Michigan and I have to come back home to the grind today. Ugh! Anyone have a suggestion for early onset post-vacation depression???

Anyway, it appears this patient has a very sick heart and a pacemaker with the lower rate limit set to just under 60. The rhythm strip shows 2:1 pacing with intrinsic AV conduction overtaking the paced rhythm. Take a VERY close look at the PR-intervals and R-R intervals to see what I'm talking about. When the patient's own heart rate hits 60 the pacemaker stops pacing.

At first I thought the 12-lead ECG showed 2:1 pacing but I looked at that prior to the rhythm strip. It shows untypable 2:1 block with nonspecific IVCD (LBBB morphology in lead V1 but negative concordance in the precordial leads which is unusual for LBBB -- this is just nitpicking).

The slight concordant ST-elevation in lead III and slight concordant ST-depressioin in aVL would be enough to make me compare to an old ECG if the patient was complaining of any s/s suggestive of ACS.

Cool ECGs!

Now how about those tips for end-of-vacation anxiety?

Tom

Tom, I have to disagree with your pacemaker statement. Although the LP 12 (which this appears to be) does not show pacer spikes on the screen, it shows them on the print out both on the strip and by printing arrows underneath the paced beats. It also notes it in the interpretation. Speaking of which, this is a good argument against relying on them.

I'd call that a 2nd degree Type II block. I wouldn't pay inordinate attention to the RBBB interpretation either. The biphasic P wave always makes me think that the patient has COPD.

Other than that, absent an acute cardiac problem that needed treatment immediately, I'd be inclined to treat the patients original complaint.

 

[TomB]

TOTWTYTR - What's up my brotha! Just for the record the pacer detector needs to be turned on for little box arrows to appear. In my experience most LP12s default to them being turned off (but of course I have no idea how this one is configured). It's the timing cycles that give the answer away in this case. The odds of a patient's intrinsic rhythm mimicking a pacemaker's behavior at exactly 1000 ms seem long to me.