Help to identify the rhythm

[Dima]

Hey folks

can you plz help me figure out the rhythm below. Im probably overthinking it, but it's not sinus arrhythmia or sinus arrest/pause. Can it be sinus exit block perhabs ? Underlying rhythm NSR @~ 80bpm.

80 yom had fall from standing, whacked his head on the floor. Asymptomatic. Thanks !

 

[chriscemt]

First. Sinus Arrhythmia.

You got p-waves, there's regularity to be found, even as irregular as it is.

There's elevation noted, but a 12 lead would be diagnostic.

 

[medichopeful]

Sinus bradycardia with frequent PACs.

Second strip is also PEA, pleth wave is flat

(Edit reason: Removed "PJCs". Upon closer inspection, I don't see any)

 

[Summit]

SR c PAC couplet (that is actually most likely a reentrant pathway) and a nonconducted PAC converting into (probable reentrant) ST
Suspicious STE question filter mode

12 lead indicated, iv, draw lytes and trops, complete assessment for fall, management based on symptoms and history, monitor for s/s subdural especially if long term anticoags, transport on monitor preferably to facility with EPL/CCL (trauma center if s/s hip or head trauma)

ddx based on the almost no information provided: unexplained fall possibly syncope related to previous sustained tachydysrhythmia you are now witnessing

 

[Dima]

Second strip is also PEA, pleth wave is flat

LOL

Thank you guys for pointing in the right direction, it looks like it's sinus brady with multiple PACs. @medichopeful the joke was actually funny lol

 

[Akulahawk]

I was going to say that since there are ups and downs, the patient isn't dead yet....

 

[MSDeltaFlt]

Uh, first strip is Sinus Bradycardia with PAC's with an added 1st degree AVB which is in the class of sinus arrhythmias. However, there is also what looks like possible ST changes. 12 lead might show inferior wall AMI. But then there is the trailing end of the second strip which is looking like either a 2nd degree AVB or 3rd degree AVB. Not enough strip to tell for certain.

 

[Summit]

Uh, first strip is Sinus Bradycardia with PAC's with an added 1st degree AVB which is in the class of sinus arrhythmias. However, there is also what looks like possible ST changes. 12 lead might show inferior wall AMI. But then there is the trailing end of the second strip which is looking like either a 2nd degree AVB or 3rd degree AVB. Not enough strip to tell for certain.

Strip 1 is SB @ 50 for the underlying rate (with probably pulsatile PACs based on pleth).
There is no 1*AVB. PRI is 200ms... maybe 210 but you are splitting hairs.

Strip 2:
I see no evidence of Mobitz I. PRI is consistent.

You could make a weak argument for an intermittent Mobitz II but there is just 1 p wave without a QRS so a nonconducted PAC is a better explanation since we saw PACs in strip 1.

There is no evidence for CHB. There is a p for every QRS and PRI is pretty consistent ~200ms. Note the QRS morphology is identical for all complexes on both strips and narrow enough to expect it to originate from within the regular conduction system. Axis also appears unchanged and the rate awful high for an escape pacemaker below the AV node.

 

[MSDeltaFlt]

Strip 1 is close enough to call it a 1AVB. A benign rhythm by itself. But there appears that there might be more going on here. Hence why a 12 lead is indicated.

Strip 2 is with 2AVB II or III. But as I said, not enough strip to tell for sure.

 

[Summit]

Strip 1 is close enough to call it a 1AVB.

Strip 2 is with 2AVB II or III.

Obviously the 12 lead would tell the truth, but with the evidence and hand, at most I could say borderline 1AVB. There is no Mobitz II or CHB that I can discern. Perhaps you'd can justify your interpretation?

 

[MSDeltaFlt]

Sure. But as I stated earlier there isn't enough strip to tell for certain. I believe this marks the third time I mentioned it. But I digress. From the first complex past the lead placement numbers the morphology does not remain the same. If you'll look closely the P waves keep getting closer and closer to the preceding T wave and it looks as though it either goes away completely or gets lost in the T wave. But for the fourth time now, there isn't enough strip to tell for certain.

 

[E tank]

Sure. But as I stated earlier there isn't enough strip to tell for certain. I believe this marks the third time I mentioned it. But I digress. From the first complex past the lead placement numbers the morphology does not remain the same. If you'll look closely the P waves keep getting closer and closer to the preceding T wave and it looks as though it either goes away completely or gets lost in the T wave. But for the fourth time now, there isn't enough strip to tell for certain.

Belly button gazing....what does the patient look like?