Second opinion on an EKG

[Aidey]

We had this patient the other day, I called the EKG one thing, the other medic called it something else. Because the ED was slammed we wern't able to ask the MD what he thought.

83 yo Female, resident in an assisted living facility. Facility staff and ALS FD first responded.

CC: Woke up SOB, "too hot", and with some diffuse pain in the back.

Initial O2 sat was 83% on RA. By the time we got there the staff had put her on 4lpm O2 via NC, fire started an albuterol tx, and she was up between 94%-96%. Lung sounds clear, no edema anywhere, chest pain went away after O2 administration.

Past history of several TIAs and occlusive strokes. Most recent one was last week "in the back of the head". Pt has some minor motor deficites on the left side from her strokes. Pt also said she has "a sloppy heart valve" and she doesn't know any more than that. Denies any heart attacks, syncope, CHF, COPD, Nausea/vomiting/diarrhea, numbness, tingling, etc etc etc.

Only meds are 81mg of ASA, 20mg of Lasix, Aricept and a few vitamins.

 

[Scott33]

The 3-lead shows sinus tach with 1st degree AVB

Can't really say much more without a 12-lead

 

[maxwell]

Too slow for a re-entrant tachycardia (no SVT). It's regular and there are no sawtooth P- wave patterns (no Atrial Flubber). The QRS isn't "wide" (no VT)...but maybe a conduction delay, need a 12 lead to say more. Sinus Tachycardia. I'm skeptical about the first degree AV block. Not that it means anything. The worry I have is most easily seen in II, aVF: a little ST depression. But, again, need a 12 lead.

 

[Scott33]

I'm skeptical about the first degree AV block.

Why? Look at the PRI, it's huge.

Don't go confusing that P-wave-looking-shape for anything other than a P-wave. The fact that it may be arguably slightly notched or peaked could be something as simple as atrial hypertrophy, or even the gain turned up on the monitor. The T-waves are inverted on lead II.

 

[MSDeltaFlt]

Yeah, can't say anything without a 12 lead.

 

[Aidey]

I couldn't save a copy of the 12 lead sorry, but it showed more of the same.

I was always taught if there was 1 box or more between the bottom of the R wave and the top of the R wave then it meant there was an abnormal conduction pathway. Has anyone else been taught this?

 

[Ridryder911]

ST with 1 degree AV block; the reason of wide QRS could be an old BBB as well the irregular ST segment is due to possible electrolyte imbalances.

The old saying .. "ah it's a 1 degree block; don't worry .. we don't treat " is a complete myth. Even such prominent things as a First degree block needs attention for possible underlying problems. Alike those that do not understand, that they are more AV disassociations than a true block. For example a Second degree type II is maybe much more worse than a third degree, as the damage has probably occurred; while the type II maybe infarcting. We get hung up on the label third degree as being alike in burns and labeled as the worst when it may not be.

Such authors and experts as Marriott, Taigman, Page will point out that all disassociations are precursors to be worried about.

Just because we may not perform treatment, does not always mean it benign.

R/r 911

 

[maxwell]

I was always taught if there was 1 box or more between the bottom of the R wave and the top of the R wave then it meant there was an abnormal conduction pathway. Has anyone else been taught this?

Specify "an abnormal conduction pathway."
An alternative pathway? No.
A conduction delay in the normal one? Maybe.

 

[ea632]

Aberrant Sinus, Regardless the patient sounds like small PE could be the issue why Neb treatment if she was clear on auscultation? ETCO2 reading / wave form could be good tool. Treat the patient not the monitor...

 

[rhan101277]

Aberrant Sinus, Regardless the patient sounds like small PE could be the issue why Neb treatment if she was clear on auscultation? ETCO2 reading / wave form could be good tool. Treat the patient not the monitor...

How hard is it to treat the patient not the monitor? Just ABC's?

 

[ea632]

Im not saying simply doing abc’s is the best treatment modality. However what I am saying is you give one Tracing to 5 cardiologist you will get 5 different interpretations with one question in common. How as the patients presentation? Its like saying " her pressure was 100/66 " good diagnostics however how was the patient i.e. mental status, chief complaint.

 

[AnthonyM83]

Why did she originally get the albuterol? What were lung sounds before it?

What did the chest and back pain feel like? Anything make it better/worse?

Skin signs? Signs of dehydration?

She might have had a pulmonary embolism, which fever often accompanies.
As was said, the slight ST depression might have been from electrolyte deficiency (secondary to her Lasix, perhaps).

I haven't heard of the pain going away with albuterol, though. Could there have been some pneumonia going on also? Or a long standing problem, then a different acute problem is what caused them to call 911.