PAC or PVC?

[Shishkabob]

13yo syncopal episode, strip taken 5 minutes after.

Medic partner said it was a PAC, after quizzing me on it for a few minutes. Looks like a PVC in 3 to me, but then again I'm still learning.

EDIT-- 30sec strip total, I can take more pics of it if required.

 

[DrankTheKoolaid]

re

pvc, note the wide complex's

 

[Ridryder911]

Your partner better get the books out! I hope they are not treating cardiac patients. Basic EKG 101: PVC wide QRS, compensatory pause afterwards, abnormal T wave from the normal set pacer.

Now I'm scared...

R/r 911

 

[MSDeltaFlt]

I will neither confirm nor deny what it is until I see a 12 Lead. Lead I seems to show a possible P wave before the complex, but it's not very good quality. That coupled with the other ectopic focused beat with a an obvious P wave earlier in the strip, then there is a chance it is just an abarrant conduction. Again, neither confirmed nor denied without a 12 Lead ECG.

 

[Ridryder911]

I will neither confirm nor deny what it is until I see a 12 Lead. Lead I seems to show a possible P wave before the complex, but it's not very good quality. That coupled with the other ectopic focused beat with a an obvious P wave earlier in the strip, then there is a chance it is just an abarrant conduction. Again, neither confirmed nor denied without a 12 Lead ECG.

PAC's usually does not have compensatory pause as well as such as a wide QRS. Abberant PAC in set pattern as well is not the usual. I am surprised that you would request a 12 to determine a PVC or not...

R/r 911

 

[MSDeltaFlt]

Because, my friend, you never say never. You never say always.

 

[firecoins]

Because, my friend, you never say never. You never say always.

Is that always the rule? :sad:

 

[medic3416]

I agree, based on what you presented they are most likely PVC’s. And I also agree that a 12 lead would be warranted. A history of syncope and PVC’s on initial limb leads = 12 lead for further investigation. Especially if all else were WNL such as RR, SPO2, BP, BG, PERRL no trauma suspected ect.

Remember that limb leads are only useful for monitoring cardiac trends and to determine rate, most rhythms and rhythm regularity. Anything else needs a 12 lead including BBB’s, nature of ectopy, ischemia, infarction, electrolyte disturbances, and conduction irregularities and so on.

 

[Ridryder911]

Because, my friend, you never say never. You never say always.

Very true, but my point to the noobies, is a 12 lead should routinely be performed as in all cases, but I would not be concern to gather another one just because I did see ectopic beats. Not judging you.. by far.

As well, many are no longer taught on the differentiation of left sided vs. right sided PVC's or to check to see if they are perfusing or not.

R/r 911

 

[medic3416]

As well, many are no longer taught on the differentiation of left sided vs. right sided PVC's or to check to see if they are perfusing or not.

R/r 911

UHmm, that’s scary. I know ACLS teaches the importance of perfusing vs non-perfusing PVC's and hopefully everyone is being taught PVC origin in cardiology as well as right precordial and posterior 12-leads.

 

[terrible one]

As well, many are no longer taught on the differentiation of left sided vs. right sided PVC's or to check to see if they are perfusing or not.

R/r 911

hopefully everyone is being taught PVC origin in cardiology as well as right precordial and posterior 12-leads.

Sorry but I never was taught the difference between R and L sided PVCs. Care to enlighten me?
thanks

 

[MendoEMT]

There appears to be quite a bit of baseline artifact so I'm not sure that there is a P wave before the complex in Lead I, but I won't rule it out. After both PVCs and PACs there is typically a pause, compensatory or otherwise... I think that the wide complex though should be a dead giveaway for a PVC though.

 

[usafmedic45]

I think that the wide complex though should be a dead giveaway for a PVC though.

Not at all. It could well be a PAC with aberrent (abnormal) conduction. You can technically have PSVT with aberrant conduction that looks for all the world like ventricular tachycardia. Just because it is wide, does not mean it's ventricular in origin.

 

[usafmedic45]

I will neither confirm nor deny what it is until I see a 12 Lead. Lead I seems to show a possible P wave before the complex, but it's not very good quality. That coupled with the other ectopic focused beat with a an obvious P wave earlier in the strip, then there is a chance it is just an abarrant conduction. Again, neither confirmed nor denied without a 12 Lead ECG.

+1. There is not enough information of sufficient quality to render a judgement.

 

[Shishkabob]

Sadly no 12 lead was available... was using LifePak 10's with only 3 leads.

 

[ResTech]

What are some possible causes of PVC's in a 13 y/o with assumingly a healthly heart? I have yet to start cardiology so curious. I know PVC's are from irritable foci originating in the ventricles and can be caused by hypoxia and certain drugs and sometimes infrequent PVC's are considered benign.

 

[Ridryder911]

Not at all. It could well be a PAC with aberrent (abnormal) conduction. You can technically have PSVT with aberrant conduction that looks for all the world like ventricular tachycardia. Just because it is wide, does not mean it's ventricular in origin.

Not denying the need, but sometimes one cannot see the trees for the forest. If I was testing you on ECG strips for the NREMT would you inform me, you would have to have a 12 lead before making an interpertation?

You would fail.

Sorry, I do respect your opinions and do understand your basis for obtaining this; but I believe we are clouding a rather simplistic ECG.

What are some possible causes of PVC's in a 13 y/o with assumingly a healthly heart? I have yet to start cardiology so curious. I know PVC's are from irritable foci originating in the ventricles and can be caused by hypoxia and certain drugs and sometimes infrequent PVC's are considered benign.

Your right many are just benign. Pediatrics have a high vagal tone as well as irritability, caffeine induced, etc..


R/r911

 

[usafmedic45]

Pediatrics have a high vagal tone as well as irritability, caffeine induced, etc..

I was going to go "Did he drink a Red Bull before this?".

If I was testing you on ECG strips for the NREMT would you inform me, you would have to have a 12 lead before making an interpertation?

You would fail.

In that situation, I would assume it's a PVC and go from there. In this case, we're looking at a non-significant finding (a single abberant beat does not tell us anything), and the quality of the EKG is not that great (no offense to the person who obtained it) so it is not going to change my assessment of the patient as I know it.

 

[daughertyemta]

PVC's. And I would agree. You don't need a 12 lead to determine thats a pvc. Thats why you have schooling.

 

[Ridryder911]

..." so it is not going to change my assessment of the patient as I know it".......

Yes, because we know we are going to treat the patient and not the monitor.

R/r 911