What Rhythm is this?

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firemedic31075

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80 y/o/m found at home sitting up in bed. Family says he got into some of his wife's cholesterol medication taking about 9-10 of them 30 mins ago. Daughter states his normal mental status is some what confused but he is a+ox3. patient denies any complaint and says he feels fine. Med Hx- hypertension, A-fib, diabetes. Meds- Insulin, metaprolol etc. VS- b/p- 140/98. P- irregular. R- 18/min. Pupils-PERRL. LS- clear+ equal bilat. Skin- warm and dry. BS- 408 (pt st's he just ate and hasnt taken his insulin tonight). EKG- see below....looks to me like it could be a few different things but was curious what you all thought.

DSCN0744.jpg


12lead.jpg
 
well....my entire class for paramedic looked at this and we came to a consensus that the p waves march out by themselves and that the rate is high probably due to his history of a-fib and that his ventricles are used to working at that rate....so i would say a 3rd degree HB....and the reason his ventricles arn't pumping at a regular rhythm is due to his known conduction issue....but how bout rid takes a stab..
 
The 12 lead is hard to read on my computer. Looks like a second degree type 2.
 
hey reaper..i thought that too but the p waves are to close together right..?
 
I'd go with second degree type II heart block.

Now to see what everyone else said it was....
 
Its controlled afib with what appears to be a ventricular conduction problem...looks like left bundle branch block in V1....
 
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Definitely not A-Fib, there is "P" waves throughout the rhythm, I too would probably call it a an AV dissociation with a BBB as well.

R/r 911
 
Definitely an AV dissociation. I'd say a 2nd Degree II. The P's march out, but not the QRS's, which makes it lower in the heart than a Wenkebach. Not fully convinced of any BBB involvement, though, due to narrow complexes in V1 (not that good of a copy, sorry).
 
Somehow my post vanished. I think if you look at the underlying atrial rate, you will see it is in excess of 200 bpm. I think what we have here is an atrial tac/atrial flutter with variable block.
 
The rate is at the high end of atrial tach and lower end for atrial flutter. The conduction pattern is variable which could be indicative of a block that could be pathological or it could be a rate regulating attempt by one of her medications. It could also be med toxicity related. If digoxin is on her list of meds, it might be time to get a level.
 
EKG Interpretation

Controlled afib - "regularly irregular", no p waves consistently attached to a qrs - multiple QRS morphologies, the guy is normotensive, his HR is 76, he has no symptoms, he is beta blocked and has a history of afib.

Whatever he is conducting is clearly coming from multiple pacemeakers and is narrow so above the junction and atrial. The QRS is not wide in VI or lead 1, lead 6 and no Rsr pattern so no LBBB.

3rd degree block? I don't see that. There doesn't appear to be any p wave marching along regular as clockwork and what is the generated escape rhythm in the absence of sinus conduction if a 3rd degree?

If you generate one from the junction his ventricular rate will be slow (40-60) and if its a IVR escape the rate will be slower still (15-40) The guy feels fine and has no symptoms.


ECG's are like people looking at a painting - great fun.

MM
 
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