Guess the EKG

[MSDeltaFlt]

The 12 lead is a few posts up. The pt self converted to 2:1 flutter before we had a chance to do anything. The rate went from 280 to 140.

There it is. Yeah, I would call it A Flutter at 2:1 even at that rate. If you look closely the waves right before the complexes are the exact same shape as those right after. And since they're all uniform, they must be the same wave.

However, I'd still call it in the field as SVT since and treat it as such.

 

[Brandon O]

There it is. Yeah, I would call it A Flutter at 2:1 even at that rate. If you look closely the waves right before the complexes are the exact same shape as those right after. And since they're all uniform, they must be the same wave.

However, I'd still call it in the field as SVT since and treat it as such.

I am extremely tickled by this possibility, as there has been something bothering me about this strip, and the "extra" bumpies are a large part of it. They do seem to march out, sort of, and the morphologies sort of match. However, flutter at an atrial rate of *600*, with a ventricular rate of *300*, in a *60* yo patient... well, I'm not sure there's much (except good bourbon) that can make me swallow that.

 

[8jimi8]

I am extremely tickled by this possibility, as there has been something bothering me about this strip, and the "extra" bumpies are a large part of it. They do seem to march out, sort of, and the morphologies sort of match. However, flutter at an atrial rate of *600*, with a ventricular rate of *300*, in a *60* yo patient... well, I'm not sure there's much (except good bourbon) that can make me swallow that.

what is wrong with those rates? what phenomenon of ectopy initiates the increased atrial rates in the first place?

 

[VFlutter]

what is wrong with those rates? what phenomenon of ectopy initiates the increased atrial rates in the first place?

I think he is referring to the comment about SVT (Even though technically A flutter can fall under the category of supraventricular Tach). I would be suspecting A flutter not SVT such as AVNRT, AVRT, or some other nodal reentry rhythm.


Also I am curious how you would treat this in regards to calling it SVT, are you considering Adenosine?. I am still hung up on the possibility of the patient having WPW leading to the 1:1 conduction which would fall into the category of preexcited A flutter. What did the 2:1 flutter look like? Delta wave?

 

[Aidey]

I'm confused what you mean about the waves right after looking the same as the waves before. The only lead with a retrograde flutter wave is lead aVr.

 

[MSDeltaFlt]

I'm confused what you mean about the waves right after looking the same as the waves before. The only lead with a retrograde flutter wave is lead aVr.

Be advised I am looking at this with my phone. But if you look at the P waves and the S waves in I, II, aVf, V5, & V6 the wave shapes all match. At rates that fast P waves, S waves, nor T waves are supposed to look alike. So, at rates that fast, if the waves look the same then odds are they will be the same.

Itself the opposite side of the same coin to determine WAP, where 3 or more P waves do not look the same Because they are originating from different places.

And yes I would treat with Adenosine unless I already knew their PMH. ECG is too fast to say WPW. But have your pads on them just in case. That is if they're symptomatic (depending on BP) in which case I'd try vagals, open fluids up (if lungs clear), give meds, then shock if not earlier depending on BP.

 

[Aidey]

Ok, I'm still confused. The whole complex in leads II and aVF look similar to each other, and the whole complex in leads V4-V6 look similar to each other but none of them are identical. I really don't understand what you mean by the S waves and T waves all looking alike. The only thing I can come up with for matching S waves is that they are all close to an 80 degree angle to the isoelectric line. I can barely even discern a T wave in that 12 lead.

 

[MSDeltaFlt]

What I mean is this. Look closely at the very top portion of each of those waves in those leads. They have similar humps/curves. Granted it is extremely difficult to look at them via cell phone regardless of pixel clarity and also at those rates. But to my eyes they look similar. Does it matter at those rates? Not really. At those rates you treat the rhythm symptomatically according to your protocols. It's still SVT any way you look at it because it is still a SUPRAventricular tachycardia.

The exact diagnosis is done after the call as you're charting and discussing with the MD, RN, and other medics,et al at the water cooler.

 

[Christopher]

As many folks pointed out, this is 1:1 atrial flutter and WPW. The shortest R:R is less than 260ms, which all but seals the diagnosis of an accessory pathway in someone 60 years of age! Even in the absence of frank delta-waves (which do not have to be present for an AP to exist), there exists no other explanation.

If they were instead 60 days old, perhaps another etiology is possible.

The likelihood of this being VT is all but absent given the rate, but it also could not be definitively ruled out. Anecdotally I have seen case reports of VT in the 250-260 range, but never higher.

SVT when used in the general sense is "correct" in that this is a rapid narrow complex rhythm originating in the atria, but in the specific sense this could not be AVNRT or AVRT (neither orthodromic nor antidromic). The AVN will simply not allow conduction at those rates and those reentry rhythms all require the AVN!

Once your rate tops about 220-240 (age dependent of course), you simply must assume that an AP is present and treat accordingly. With 1:1 conduction over an AP present, adenosine certainly will not solve the problem. Ca-channel blockers and B-blockers are also absolutely contraindicated.

Procainamide is often quoted as "safe in WPW", but with a rhythm like atrial flutter as the mechanism, you could run into trouble. While procainamide will slow conduction through the AVN and AP, it will also slow the flutter circuit which potentially could dip into the range conductible by the AVN!

I think the only course of action in an unstable patient with 1:1 atrial flutter is cardioversion. I agree with Tom that if we could, I would take a ride with this patient and monitor them. Otherwise, I would sedate and cardiovert.

I've attached an example of a 1:1 flutter I mistakenly treated as VT with lidocaine, prior to my introduction to proper WCT treatment, which thankfully ended up working.

Great case!

 

[Melbourne MICA]

Dizzy

Atrial flutter 1:1

A rate @ 300/min (new QRS every 1 lrge square) and a narrow complex saw tooth pattern suggest the rhythm is above the junction. Such a rate is unlikley to be sustained in the ventricles.