Name the Rhythm: 52 year old male

Christopher

Christopher

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52 year old male, called 911 because he has felt "sick and weak" and doesn't seem to be getting any better.


(click image for larger version)

You ain't getting anything else, but I'd like a rhythm interpretation :)

Rate?
Regularity?
P-waves?
PR interval?
QRS duration?
Rhythm DDx?

Axis?
QTi/QTc?
ST/T-wave changes?
Overall DDx?
 
You should blot out the answers to half your questions on the image.

Anyhoo, atrial tach. Given the short duration ST evaluation is generally hampered and it is reasonable to state that changes at that rate have a good chance of being rate-related. R/O fever/other causes of tachy and then you can elect to treat rate. Could trial adenosine.
 
No argument that blind trust in the machine is a bad idea - hence why ECGs are overread by people in context. That said, one thing the LPs are good at is math. The calculations for intervals etc. are generally good, even if the interpretation based on the algorithms is sometimes a miss.
 
Merck said:
No argument that blind trust in the machine is a bad idea - hence why ECGs are overread by people in context. That said, one thing the LPs are good at is math. The calculations for intervals etc. are generally good, even if the interpretation based on the algorithms is sometimes a miss.
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I don't disagree, I take the following calculations with a grain of salt until I calculate them myself: Rate, PRi, QRSd, and QTi/QTc.

Axis is almost always spot on.

The calcs are all pretty good if the rate is between 50 and 120. Otherwise, I'm going to work it thru myself.
 
Christopher said:
52 year old male, called 911 because he has felt "sick and weak" and doesn't seem to be getting any better.


(click image for larger version)

You ain't getting anything else, but I'd like a rhythm interpretation :)

Rate?
Regularity?
P-waves?
PR interval?
QRS duration?
Rhythm DDx?

Axis?
QTi/QTc?
ST/T-wave changes?
Overall DDx?
Click to expand...

This is the best I could fathom, I printed it out to read it and it came out grey and half the size of a normal 12Lead and I don't get all of the leads :(

Alright lets see

Rate of around 180 if I counted right
Regular
PR of 0.08
I cannot tell the QRS duration on my print out but looks like almost a 0.08

Looks like SVT

Normal Axis
There are some ST changes, but also BER is present
 
Fish said:
This is the best I could fathom, I printed it out to read it and it came out grey and half the size of a normal 12Lead and I don't get all of the leads :(

Alright lets see

Rate of around 180 if I counted right
Regular
PR of 0.08
I cannot tell the QRS duration on my print out but looks like almost a 0.08

Looks like SVT

Normal Axis
There are some ST changes, but also BER is present
Click to expand...

Which half printed out? The precordials are almost more interesting than the limb leads.

As for the ST-changes: I would caution against interpretation when rates >110ish as they are usually obscured to where it is difficult to observe certain conditions. I don't know if BER is present in this patient, but it is difficult to say for certain with the tachycardia.

I had a private message from a novice interpreter and I gave them the following advice regarding ST-changes in tachycardias:
As for ST-elevation in V4-V5, anytime you have a profound tachycardia, e.g. rate >110, I would not read much into any perceived ST-elevation. In fact, if you find the J-point for those two leads, you'll notice the J-points are actually depressed!

Both of those leads have an RS complex, which means they have an R-wave then an S-wave. Where the S-wave meets the T-wave, our J-point, is below the isoelectric line...which is also hard to find because of the tachycardia!

It is pretty common to get J-point depression in tachycardia due to either atrial repolarization (advanced concept) or demand ischemia (simple concept).

Basically, the only way you get STEMI + profound tachycardia is Cardiogenic Shock! This patient does not have that going on thankfully.
Click to expand...
 
I would guess MAT, there appears to be P waves of various morphology buried in the T waves.
 
Christopher said:
Which half printed out? The precordials are almost more interesting than the limb leads.

As for the ST-changes: I would caution against interpretation when rates >110ish as they are usually obscured to where it is difficult to observe certain conditions. I don't know if BER is present in this patient, but it is difficult to say for certain with the tachycardia.

I had a private message from a novice interpreter and I gave them the following advice regarding ST-changes in tachycardias:
Click to expand...

V3 was where it cut off, I cannot see V4-V6this is certainly not Diagnostic for a STEMI, but concave elevation and notching just after the S wave can be seen leading me to believe BER, which is commonly seen with the young, thin chest waves, even tachy rythms. Occassionally I can find the edge of a P wave, but they mostly appear burried.

What did you interpret it as?
 
Fish said:
V3 was where it cut off, I cannot see V4-V6this is certainly not Diagnostic for a STEMI, but concave elevation and notching just after the S wave can be seen leading me to believe BER, which is commonly seen with the young, thin chest waves, even tachy rythms. Occassionally I can find the edge of a P wave, but they mostly appear burried.

What did you interpret it as?
Click to expand...

BER is uncommon >50 years old (I don't have a reference handy for this).

As for my interpretation...I don't want to bias any interpretation for a bit :)

I know what the original crew called it and what they did as well.
 
So I see the peaked t-waves, I see the narrow QRS, I see the rate. I can justify calling that SVT, but am hesitant to treat it aggressively, without confirmation, as long as the patient remains stable. WIthout vitals, a fluid bolus and vagal maneuvers sounds to be an order.

The ST elevation isn't diagnostic because of ?abberancy?. In order to diagnose, would either need to slow down the heart or slow down the printing.
 
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emt.dan said:
So I see the peaked t-waves, I see the narrow QRS, I see the rate. I can justify calling that SVT, but am hesitant to treat it xx, without confirmation, as long as the patient remains stable. WIthout vitals, a fluid bolus and vagal maneuvers sounds to be an order.
Click to expand...

Reasonable interpretation.

emt.dan said:
The ST elevation isn't diagnostic because of ?abberancy?. In order to diagnose, would either need to slow down the heart or slow down the printing.
Click to expand...

Aberrancy refers to abnormal conduction through the bundle branches, which in this case is not present. The QRS duration is normal indicating rapid transmission through the bundle branches into the Purkinje system.

Moreover, although classically we have been taught that bundle branch block means you can't "interpret a STEMI", we have known since the 1990's that this actually is not true. Aberrancy does not render the ST-segments non-diagnostic. You can interpret the ST-segments in both RBBB and LBBB for STEMI. Oddly enough it has taken until ~2006 for most of cardiology to catch up with the literature and until only very recently for the rest of medicine to catch up.
 
As for treatment....... Well, I know you didn't ask for our treatment. But obviously one would need a lot more to know what our treatment would be.


My interpretation is just based off the ECG print out and the age/CC
 
I'd say this is SVT and do not think this is an active STEMI, although "sick and dizzy" does make me worry a bit. I'd look for signs/symptoms of hypovolemia and/or dehydration and treat with fluid first, unless his BP was through the roof. If that didn't work I'd consider adenosine to see if we could slow the heart rate down and see what underlying rhythm is.
 
Almost looks like a Sinus rhythm to me.

When you look close there seems to be a changing morphology in the T-Wave though which is probably from the p and t waves being merged together because of the rapid depolarization. Would suspect irritated atria.
 
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Slight hints of a WPW. Not saying it is, but could see the argument, look at lead 3.

Disagree with MAT.

Could also be plain old svt. Not really seeing the atrial tach either.
 
Thricenotrice said:
Could also be plain old svt. Not really seeing the atrial tach either.
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What would you consider plain old svt?

The rhythm is without a doubt some sort of supra-ventricular tachycardia. You know that SVT is used to describe a group of possible causes when the rate is too fast to differentiate the correct one.

Is it coming from the sinus node, atria, av junction, or an accessory pathway like you said?

Interested to hear the final diagnosis.
 
Sublime said:
What would you consider plain old svt?

The rhythm is without a doubt some sort of supra-ventricular tachycardia. You know that SVT is used to describe a group of possible causes when the rate is too fast to differentiate the correct one.

Is it coming from the sinus node, atria, av junction, or an accessory pathway like you said?

Interested to hear the final diagnosis.
Click to expand...

Ya my bad. Didn't type what my mind was thinking. I was thinking "plain old svt" as a sinus rhythm.
 
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