Fun in EKG Rhythm Analysis

[wrmedic82]

Hey ya'll. Its been too long since I've been on here. Been going to school and working in cardiac telemetry. For those who don't know me (which may be a lot of you) I love learning about EKG's, and I realize many people determine them differently. I have a couple teaser rhythms that I will post here occasionally until I get bored or no one responds. But please give these a shot, be civil to others interpretations if you disagree and I will reveal the answer later.

Just some background on this patient. 69 y/o female on a holter for having "spells". The patient's baseline rhythm is Sinus with a First Degree AV block with IVCD (intraventricular conduction delay). Unknown if the patient has a history of bundle branch block. Thats one of the disadvantages to holter rhythm analysis. So if you want to assume there is one, I wont hold it against you unless you call it a right or left bundle branch block. Identities have been of course withheld for protection of the cardiac offenders (due to HIPAA). There are 3 strips I saved. the first three ( assuming it puts them in the order I uploaded them in) are a continuous strip encompasing a total of 18 seconds. I would have put another one up but it seems I have exceeded the bandwidth. I will try and add it shortly as a comment if possible. (It's been a while)

The program being used is called Pocket ECG. Enjoy

The 4th strip is too large for me to post. If you would like the last strip email me at wrmedic82@yahoo.com.

Thanks

Edited December 20, 2010 by wrmedic82

[fiznat]

Ah, does this patient have a pulse?

[wrmedic82]

Ah, does this patient have a pulse?

Yes. Patient shortly after this called in to report having a "stinking spell". Could not get any specifics other than that from the patient per the supervisor that took the call.

[Kiwiology]

Oh dear, this gentleman is quite unwell .... um, could be any of the above

[wrmedic82]

I will add that after this episode, the patients HR stayed between 32-34 bpm.

Edited December 20, 2010 by wrmedic82

[mobey]

I have only seen this once before.

I called it Sinus arrest.

The Gal I saw was having multiple syncopal episodes. I was pretty close to startin CPR a few times. Hard to tell bt the 3 strips if this is a regular rythm since they are short with only 1-2 beats. If they are regular, it can be called a sinus brad. Otherwise Sinus arrest fits good enough for me.

[Just Plain Ruff]

I have only seen this once before.

I called it Sinus arrest.

The Gal I saw was having multiple syncopal episodes. I was pretty close to startin CPR a few times. Hard to tell bt the 3 strips if this is a regular rythm since they are short with only 1-2 beats. If they are regular, it can be called a sinus brad. Otherwise Sinus arrest fits good enough for me.

I think this is a sick patient. She just doesn't know it yet.

This is what killed my father in law I believe. COD for him was Cardiac arrest but I'll bet this is exactly what happened to him. He collapsed over the toilet and his heart could not fill enough to keep him alive.

But this patient would be in a helicopter going to our cardiac center with all the strips I could muster for them. I think a pacemake is in order for this person.

[mobey]

I dunno if your looking for treatments or not, but here is mine.

First line would be 0.5mg Atropine I.V.

Second line would definatly be paced ASAP.

If needed, Fentanyl could be used for immediate pain control. However once the BP is stabilized, I may add in Versed and switch to morphine since I have transport times greater than 3hrs to Cardiac unit.

I dunno if your looking for treatments or not, but here is mine.

First line would be 0.5mg Atropine I.V.

Second line would definatly be paced ASAP.

If needed, Fentanyl could be used for immediate pain control. However once the BP is stabilized, I may add in Versed and switch to morphine since I have transport times greater than 3hrs to Cardiac unit.

[DwayneEMTP]

Man, I'm going out into left field and going to take a guess at hypocalcemia.

What shot me off in that direction is that I thought that maybe there was a hind of a J wave in the 3rd strip. Also, it appears to me that there is electrical activity at a rate of about 74-76bpm but that the muscle is only responding on about every 6th beat, which leads me to believe that though there might be an electrical element here I would be more prone to believe that it's electrolytes or toxicologic. I can't intelligently defend this stance as its more of a feeling, or intuition that the result of a logical path, but I do have a feeling that I'm somewhere in the neighborhood. Electrolytes feel right though only because I can't think of many other reasons for the heart not to be responding to the delivered impulses regularly.

Having said that, I don't know what other symptoms might accompany hypocalcemia, nor what I would do emergently to treat it, nor what may have caused it (My brain keeps showing me toothpaste, but I have no idea what that might be about.). I've never wanted to google an answer so bad before posting in my entire friggin' life as I know I'm missing something obvious and am going to end up looking like a bigger dumbass than usual.

So my treatment here would be O2, apply pacing/defib/3lead pads, IV, Atropine 0.5mg, and hope like hell that I don't get to the hospital to hear the doc say, "What? Are you a complete moron!?! This is obviously X!! All you had to do was Y!!"

So there you have it. Awesome case..I look forward to further conversation.

Dwayne

Edited to adjust formating.

Edited December 21, 2010 by DwayneEMTP

[wrmedic82]

The thread was for rhythm analysis purposes, however if you want to specify your course of treatment thats fine too. The main purpose is purely educational