Intresting ECG- Can't quite put my finger on it.

B

bakertaylor28

Forum Lieutenant
Messages
198
Reaction score
20
Points
18
Mind you I know we don't see 3-lead ECG as much as we used to, but I'm rather old-school. I can't quite decide for myself if this one is artifact, or exactly what's going on- but take notice of the second and third complex in lead II. I want to say that this is a PJC, but not sure what the deal Is with that giant T wave preceding it (in proportion to the rest of the strip anyways...)

Mind you the reason I don't think this is artifact is because it distinctively reappears every 10 seconds or so in a 30 second strip.
2i6glk.jpg
 
Blocked PAC causing that P-T fusion and then a junctional escape beat.
 
Chase said:
Blocked PAC causing that P-T fusion and then a junctional escape beat.
Click to expand...
Interesting you noticed the detail - I hadn't considered the notion of a P-T fusion there as with a fusion I would have expected a less smooth morphology... but looking at it closely I see exactly where the fusion is in the morphology. Of course, the junctional escape (PJC) I noticed, but kind of took a harder look at it as time hasn't been good to my eyes with this sort of thing....
 
@Chase I'm with you on the P-T fusion at the end of the second complex but I dont think the following complex (#3) is an a junctional escape beat. For one thing isn't it to quick to be a junctional escape beat? Junctional rhythms are usually 40-60bpm and this quite a bit quicker. I'm wondering if there are ectopic atrial impulses firing and the #3 complex was just an ectopic atrial beat. It is clearly originating from a different impulse but its not premature or out of sync with the rest of the strip.
 
@Captainindepth... The morphology of the beat in question fits accelerated junctional Rhythm. (inverted or absent P with a short PR interval and a and otherwise normal QRS, and a rate of 60-100, but there's only ONE of them, hence it is a junctional excape beat / Premature Junctional Complex. (PJC) This works the same way as PVCs- we can have them isolated within normal beats- or if we have them one right after another, we call them v-tach. (assuming the rate to be fast enough to be a tachycardia.)
 
And how exactly will this 3-lead ECG dictate our treatments?

Old skool or not, advances in medicine and technology happen for a reason. In this case, 12-lead ECG's (and serial ones at that) should this otherwise benign tracing change into the patient becoming symptomatic.
 
bakertaylor28 said:
@Captainindepth... The morphology of the beat in question fits accelerated junctional Rhythm. (inverted or absent P with a short PR interval and a and otherwise normal QRS, and a rate of 60-100, but there's only ONE of them, hence it is a junctional excape beat / Premature Junctional Complex. (PJC) This works the same way as PVCs- we can have them isolated within normal beats- or if we have them one right after another, we call them v-tach. (assuming the rate to be fast enough to be a tachycardia.)
Click to expand...


I agree the complex of the #3 beat is different than the rest of the complexes and its an ectopic beat. The fact that it is at the same rate ( R-R is not different in reference to beats #2 and #4 or the rest of the strip for that matter) I believe it is an ectopic atrial beat. Junctional escape beats occur when there is not a SA or atrial impulse and the AV node usurps and initiates the impulse for the ventricles to fire. premature junctional complex (PJC) occurs when the AV node (or surrounding cells) fire PREMATURELY causing the ventricles to fire prematurely and the QRS complex to be out of sequence with the rest of the rhythm (early). This beat is in rhythm and not out of sequence, just a different morphology.

Of course all of this nit-picking has very little consequence when it comes to patient care. And like @VentMonkey said above this is a very benign EKG and im sure the one beat in questions has little to no effect on the patients presentation, which is the most important thing.
 
VentMonkey said:
And how exactly will this 3-lead ECG dictate our treatments?

Old skool or not, advances in medicine and technology happen for a reason. In this case, 12-lead ECG's (and serial ones at that) should this otherwise benign tracing change into the patient becoming symptomatic.
Click to expand...

This really has nothing to do with treatment, but rather everything to do with reading lead II rhythm strips in particular. The point and purpose is limited to that and nothing else.
 
captaindepth said:
I agree the complex of the #3 beat is different than the rest of the complexes and its an ectopic beat. The fact that it is at the same rate ( R-R is not different in reference to beats #2 and #4 or the rest of the strip for that matter) I believe it is an ectopic atrial beat. Junctional escape beats occur when there is not a SA or atrial impulse and the AV node usurps and initiates the impulse for the ventricles to fire. premature junctional complex (PJC) occurs when the AV node (or surrounding cells) fire PREMATURELY causing the ventricles to fire prematurely and the QRS complex to be out of sequence with the rest of the rhythm (early). This beat is in rhythm and not out of sequence, just a different morphology.

Of course all of this nit-picking has very little consequence when it comes to patient care. And like @VentMonkey said above this is a very benign EKG and im sure the one beat in questions has little to no effect on the patients presentation, which is the most important thing.
Click to expand...

BUT we know that that a negative P wave indicates retrograde conduction from the AV into the atria- therefore, how can we say that we have an atrial origin? and its not nitpicking- I'm just trying to see your thought process clearly considering an MD agreed this was a PJC (and I'd love to be able to ROAST the particular MD in question for even the slightest detail.)
 
Any cell in the atria can be the source of an ectopic beat and where that cell is located in the atria effect the morphology of the P wave but the QRS will remain narrow and can appear to be the same as the underlying rhythm. In this case the rate at which the beat (#3) occurs and the QRS morphology being the same as the underlying rhythm leads me to think its an ectopic atrial cell firing but the normal AV/junctional/ventricle firing in response to the impulse. This not a premature complex but is the result of an ectopic impulse.


https://lifeinthefastlane.com/ecg-library/premature-atrial-complex-pac/
 
Very rational and possible. But ,if that's a blocked PAC before it, wouldn't the compensatory pause from the PAC (where I was taught that anytime you have PAC you'll have compensatory pause after the PAC) push the complex to the right, and hence back into the normal position (or close enough), being the reason we don't see an early complex? so that what we "see" is a regular R-R interval, but we have two things going on that balance out to make the R-R appear to be in synch with everything else? Here, we see an 8mm pause after the fusion beat, so being conservative, since the pause is going to push everything after it to the right, lets say we move our complex in question 4 mm or so to the left. Then we no longer have a regular R-R.
 
But w that I read through that link... your reasoning makes perfect sense- I double checked the P-R interval and it's actually NOT short enough for PJC- and when I look at it closely it does look like a PAC- though, I wasn't thinking PAC could have a negative axis- hence wasn't looking for it- :-) so it appears I was taught incorrectly- imagine THAT.
 
bakertaylor28 said:
Very rational and possible. But ,if that's a blocked PAC before it, wouldn't the compensatory pause from the PAC (where I was taught that anytime you have PAC you'll have compensatory pause after the PAC) push the complex to the right, and hence back into the normal position (or close enough), being the reason we don't see an early complex? so that what we "see" is a regular R-R interval, but we have two things going on that balance out to make the R-R appear to be in synch with everything else? Here, we see an 8mm pause after the fusion beat, so being conservative, since the pause is going to push everything after it to the right, lets say we move our complex in question 4 mm or so to the left. Then we no longer have a regular R-R.
Click to expand...


Annnddddd........I'm lost.

I see where your thinking is at but I think its goes a little past just interpreting the EKG in front of us and into hypothetical scenarios.

(Also when regarding the horizontal axis the unit of measure is time not distance.) :)
 
@captaindepth- the OP isn't worth feeding...constantly.

@bakertaylor28- if the point of your thread here was to confirm your suspicions so that you can prove some other doctor wrong, your arrogance and narcissism supersedes any of your threads or posts in your posting history.

I am not downplaying the gobs of knowledge shared on this forum from many walks of life, but short of asking a room full of cardiologists, I hardly think that this would be the place to obtain your confirmations.

This site is for learning and sharing, perhaps you learned something with the knowledge shared by other posters in this thread, which is great, but know when to call it quits.
 
captaindepth said:
Annnddddd........I'm lost.

I see where your thinking is at but I think its goes a little past just interpreting the EKG in front of us and into hypothetical scenarios.

(Also when regarding the horizontal axis the unit of measure is time not distance.) :)
Click to expand...

Actually it's distance in mm per unit of time- using distance to measure time... (i.e. 25 mm / sec) making horizontal distance and time synonymous. However, calipers don't measure time- hence articulating it in such a way perhaps I caused a confusion in exactly where I was going. The notion is that anytime you have a pause, no mater how brief, the pause is going to make everything that comes after it (I.e. everything thing to the right) come later than usual, hence the pause pushes things to the right on the horizontal axis, and because with PJC we expect something to happen early, it wouldn't "appear" early because the pause "corrected" the early appearance enough to push it back into it's "regular" position. however, a PJC wouldn't have a fusion in the wave, and here I notice (after looking a little more carefully) what is actually two P waves fused immediately before the QRS with the negative axis- I was just too quick to dismiss the first half of it as artifact, and interpreting the second as the P- but even then the PR interval is too long for PJC. Hence we have a blocked PAC fused to the T-wave and then a conducted PAC with the QRS following it. I wouldn't expect two pacs that far apart (8 mm or 0.16 sec) hence it didn't quite register that way in my mind until I really looked close and noticed the second buried wave in there. Its also coming from the rationale that since the pac fused to the T wave Didn't conduct, one would rationally expect that the AV is going to try to make the QRS happen on schedule. Hence you'd expect to see a PJC after a PAC in order to terminate the PAC in order to keep the QRS on schedule in the bigger picture.
 
VentMonkey said:
@captaindepth- the OP isn't worth feeding...constantly.

@bakertaylor28- if the point of your thread here was to confirm your suspicions so that you can prove some other doctor wrong, your arrogance and narcissism supersedes any of your threads or posts in your posting history.

I am not downplaying the gobs of knowledge shared on this forum from many walks of life, but short of asking a room full of cardiologists, I hardly think that this would be the place to obtain your confirmations.

This site is for learning and sharing, perhaps you learned something with the knowledge shared by other posters in this thread, which is great, but know when to call it quits.
Click to expand...

OK, sorry I didn't INFORM you of the nature of the relationship I have with this person. There's a difference between friendly roasting and arrogance. As they say Iron sharpens Iron.... (since some of the MDs don't read EKG nearly as frequently as we do in the emergency setting.) That's what I sort of intended out of the comment. So yeah, you took that ENTIRELY the wrong way.
 
I totally get trying to be correct as possible, I was a monitor tech for years, however in all honesty it really doesn't matter. Do it for your own curiosity not for you to show up another provider. You can try to tell someone the rhythm they are calling Atrial Flutter is actually Atrial Tach due to the Atrial Rate or that it's polymorphic VT and not Torsades because of the QT interval but you just end up sounding pretentiousnes. Most providers except an Electrophysiologist isn't going to notice those minute differences. Unless it's something that drastically changes clinical care, let it go.

There is always that saying you ask 2 cardiologist about a rhythm and you get 5 answers. Most of the time it's just semantics and educated guesses. It's Emergency Medicine not the EP lab.
 
Chase said:
I totally get trying to be correct as possible, I was a monitor tech for years, however in all honesty it really doesn't matter. Do it for your own curiosity not for you to show up another provider. You can try to tell someone the rhythm they are calling Atrial Flutter is actually Atrial Tach due to the Atrial Rate or that it's polymorphic VT and not Torsades because of the QT interval but you just end up sounding pretentiousnes. Most providers except an Electrophysiologist isn't going to notice those minute differences. Unless it's something that drastically changes clinical care, let it go.

There is always that saying you ask 2 cardiologist about a rhythm and you get 5 answers. Most of the time it's just semantics and educated guesses. It's Emergency Medicine not the EP lab.
Click to expand...

I see your point, and it is taken well. I see these sort of things as exercises in making the eye more keen to picking things up that we might not see otherwise. Its easier to start doing this where there isn't anything going on in the big picture and then to get more advanced as one trains the eye. Rather, I see it as a "back to basics" exercise, as I'm experimenting with a technique to make those whom are well to do with reading ecg even faster at catching things, to where less slips through. I thought I'd try this one out because I was sort of stumped by it, even though we know its not of consequence. It just makes one less confident of catching that which IS of major significance. If you see where I'm going.
 
FlyingSalt said:
Wandering atrial pacemaker?

Sent from my SM-G900V using Tapatalk
Click to expand...

Very possible. You could argue there are 3 or more P wave morphologies however there appear to be dropped beats so those beats after should be ectopic.
 
You must log in or register to reply here.
Back
Top