Strip to Interpret

[jwright367]

This is a scan of a strip I had few days ago. I spent several hours in Photoshop darkening the lines and superimposing the graph paper behind it so I can use it on a test. I'm trying to get an idea from other medics on how difficult this is to interpret so I know how fair or unfair it will be on the EKG final for my Cardiology class. The patient was a 65 year old male that was totally asymptomatic and had a blood pressure of 124/80. He called us out because he has been feeling a little bad for the past 3 weeks and gets dizzy and short of breath when he gets up and moves around. What a surprise!

The waveform under the lead II waveform is the SPO2.

The link below is the answer key to what all the different waves are.
http://s767.photobucket.com/albums/xx311/jwright367/?action=view&current=MegaEKGANSWER.jpg

 

[fma08]

looks like a complete heart block to me... or in the words of a former instructor of mine, "That's a f***ed up rhythm"

 

[jwright367]

You are correct, and so was your instructor. Did you notice anything odd aside from the fact that it was a complete heart block?

 

[Shishkabob]

It looked like a junctional rhythm with some re-entry up till halfway through the first strip, then no more re-entry from that point on.

I didn't even think of a 3rd degree block until FMA said so... I just didn't see any continuation of the P waves to make me think of such.


What really confused me, was I thought they were really small complexes, because I was expecting a ventrical foci to pick up on the missed stimuli and start beating on their own... which is why I thought the P's were R's, and the R's were P's

 

[Melclin]

I would say this is a fairly difficult strip to interpret. I thought it looked like some 3rd degree heart blocks I'd seen. But if I were to go through it systematically and analyse the thing, identifying atrial R&R, ventricular R&R etc, I would have had alot of difficulty coming to any conclusion. So I couldn't tell you why it look like a complete heart block, just that it did and that's obviously a big problem on an exam.

I would say that this is a relatively difficult rhythm to interpret for students on an exam, given the ambiguity of the waves. T, P and R waves all look pretty similar. How experienced are they? How much cardiology and ECG work have they done?

 

[jwright367]

The students that will be taking the exam are EMT's that are going through Paramedic school. The cardiology portion of their school lasts for about a month going 2 nights a week. So yea, it might be a little hard. However, this is a strip that I saw in the field, so they need to be able to identify a strip like this. And once you start labeling the P waves, and the QRS segments that are obviously QRS segments (the first 5 on the top strip), its pretty easy to see the disassociation between the atrium and ventricles. Thanks for all the input.

 

[Ridryder911]

Classic complete block w/variable atrial rate.

R/r 911

 

[jwright367]

Classic complete block w/variable atrial rate.

R/r 911

Did you mean variable ventricular rate? When I marched out the P waves, I didn't see more than a box and a half of difference throughout the whole strip. Click the link under the picture, I labeled what i thought were the P waves.

 

[Melclin]

The students that will be taking the exam are EMT's that are going through Paramedic school. The cardiology portion of their school lasts for about a month going 2 nights a week. So yea, it might be a little hard. However, this is a strip that I saw in the field, so they need to be able to identify a strip like this. And once you start labeling the P waves, and the QRS segments that are obviously QRS segments (the first 5 on the top strip), its pretty easy to see the disassociation between the atrium and ventricles. Thanks for all the input.

Wait, so they do about eight nights of cardiology and that's it? Surely that's just one of the cardiology requirements.

Yeah I see what you mean, and I definitely agree that they need to be able to interpret it on the road. If the exam is for the only class on cardiology they have then definitely put it on. I just thought if the class was introductory it might be on the harder side. We have way more A&P and time to digest and understand information in my degree than you guys do and plenty of the people in my class would have trouble with that rhythm (as yet, we have only covered introductory interpretation).

 

[Ridryder911]

Did you mean variable ventricular rate? When I marched out the P waves, I didn't see more than a box and a half of difference throughout the whole strip. Click the link under the picture, I labeled what i thought were the P waves.

Sorry early a.m. post, your right wrong wording. I too am concerned that one only has one month of cardiac care lectures... the minimum should be at least three to six months.

R/r 911

 

[jwright367]

Wait, so they do about eight nights of cardiology and that's it? Surely that's just one of the cardiology requirements.

Yeah I see what you mean, and I definitely agree that they need to be able to interpret it on the road. If the exam is for the only class on cardiology they have then definitely put it on. I just thought if the class was introductory it might be on the harder side. We have way more A&P and time to digest and understand information in my degree than you guys do and plenty of the people in my class would have trouble with that rhythm (as yet, we have only covered introductory interpretation).

Sorry, I worded how long their class is wrong. They have about 20 class days that go from 6pm to 10pm at night. So its almost a months worth of class days over a period of 2 months. By the time we get to their EKG final, we will have gone over every rhythm extensively. And they have 6 other tests during the semester, so the EKG final is only covering rhythm strips.

 

[Melclin]

Sorry, I worded how long their class is wrong. They have about 20 class days that go from 6pm to 10pm at night. So its almost a months worth of class days over a period of 2 months. By the time we get to their EKG final, we will have gone over every rhythm extensively. And they have 6 other tests during the semester, so the EKG final is only covering rhythm strips.

Oh then in that case, it shouldn't be to hard at all. Sounds good.

 

[Ditchmedic]

Looks like third degree to me.

 

[medic_texas]

Looks like a run to the cath lab to me

3rd degree