Another interesting EKG

Gurby

Gurby

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73 F, 300+ pounds, short of breath and weakness for 1 week. Denies any significant history, apparently does not take any meds. Satting at 90 on room air, 140/90.
ekg edited2.jpg
 
Hmm. Wide complex tachycardia. Polymorphic.

Was this the only ekg? the pt was a&o? With a pulse?
 
I really wish you'd start getting 6 second strips.
 
I'd call it atrial fibrillation with rapid ventricular response and right bundle branch. Very fast A-fib RVR though! Poor guy had probably been in it for the entire week, no wonder he is weak and SOB.

Irregular with no discernable p-waves. Wide QRS complexes with large terminal R-wave in V1 and terminal S-waves in V6, suggest RBBB pattern. The QRS don't have a alternating pattern that would suggest Torsades (they have the same morphology throughout each lead). Obese and older, consistent with a-fib all on it's own. Random thought (just to throw in the differentials), PE can contribute to new A-fib and and RBBB, and might help explain the low pulse ox.

Fun EKGs, thanks for sharing :)
 
What he said. AF c RVR and RBBB.

Wish I would have saved the strip, but I had a bradycardic atrial flutter last week. Was pretty neat.
 
Same as what the others have said. A-Fib RVR with a RBBB.
 
teedubbyaw said:
I really wish you'd start getting 6 second strips.
Click to expand...

A nice long rhythm strip would be nice here. I'm pretty sure it's just AFib with RVR and a RBBB.... But after the call I started questioning possibility of flutter with 2:1 and maybe even an accessory pathway. Textbook says to consider this any time you see a rate of 150. Notice that there are basically two different R-R intervals present - a shorter and longer one. The shorter ones are at a rate of ~300bpm, and the slower ones are ~150bpm. A lot of the pauses are compensatory. I question whether the AV node is capable of firing as fast as it is in some places here (wikipedia says it takes 0.12 seconds to cool down, so theoretically it is...).

However... I think it's not quite consistent enough for this to be the case. There are enough R-R's that don't quite fit into this pattern/theory, and it's such a zebra, that IMO it's almost certainly just AFib. Fun to think about, though. The fact that she is 73, 300 pounds and "has no medical history" says to me that she is never seen by a doctor, so it's possible she could go this long in life without discovering she has LGL or something like that. Some of the leads almost look like they have delta waves as well...
 
However the baseline is pretty chaotic and at least I'm not seeing any kind of flutter waves.
 
Gurby said:
However... I think it's not quite consistent enough for this to be the case.
Click to expand...

3 tips for assessing regularity:

1. In almost all 12-lead print-outs, even without a simultaneous rhythm strip, the actual tracing from left to right is still continuous. In other words, as you move across the four columns of three leads each, you are moving through time, and although the view changes as you switch into each new "set" of leads, it's still displaying three simultaneous, uninterrupted rhythm strips in a manner of speaking.

2. Step back and look from a distance. Irregular irregularity, clustering, and other patterns are much more easily appreciated this way.

3. Get some actual calipers to march out the rhythm. Especially at faster rates, the very small differences in R-R are not apparent by eyeballing, and only semi-apparent with ghetto calipers like marks on paper.
 
Brandon O said:
3 tips for assessing regularity:

1. In almost all 12-lead print-outs, even without a simultaneous rhythm strip, the actual tracing from left to right is still continuous. In other words, as you move across the four columns of three leads each, you are moving through time, and although the view changes as you switch into each new "set" of leads, it's still displaying three simultaneous, uninterrupted rhythm strips in a manner of speaking.

2. Step back and look from a distance. Irregular irregularity, clustering, and other patterns are much more easily appreciated this way.

3. Get some actual calipers to march out the rhythm. Especially at faster rates, the very small differences in R-R are not apparent by eyeballing, and only semi-apparent with ghetto calipers like marks on paper.
Click to expand...
I find the old method of folding the paper back on itself and holding it to a bright light to work pretty well
 
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