BEorP Posted July 23, 2013 Posted July 23, 2013 (edited) This isn't an actual patient I saw but rather just a practice ECG. The clinical information is that it is a 66 year old female with palpitations. I'll share my thoughts on it later (since I've looked at the answer I don't want to spoil it... I'm interested in seeing if anyone saw what I thought I saw). The ECG should be attached. Edit: looks like the attachment didn't work but at first but it should be attached now Edited July 23, 2013 by BEorP
BushyFromOz Posted July 23, 2013 Posted July 23, 2013 (edited) Atrial fib with suggestion of left ventricular hypertrophy? The image is really weird on my screen, i cant see the grid lines Edited July 23, 2013 by BushyFromOz
paramedicmike Posted July 23, 2013 Posted July 23, 2013 The rate appears to be about 150. There are no p waves. The rhythm is ever so slightly irregular. Axis is pretty normal and V1 and V5 aren't too bad. Intervals look good and there's no ST elevation. While I wouldn't call it necessarily call it controlled at the moment I do agree with A-fib. This being said I saw an EKG earlier today that looked pretty similar to this one. It was treated as an SVT and adenosine slowed it down enough to reveal flutter waves. However, short of any additional clinical picture I'll stick with the A-fib for now.
Kaisu Posted July 23, 2013 Posted July 23, 2013 You're right, the rate is over 100. I couldn't see the boxes, although I guess I should have just judged it from the density of complexes....
Mateo_1387 Posted July 24, 2013 Posted July 24, 2013 ... I'm interested in seeing if anyone saw what I thought I saw).... On the bottom lead (I assume lead II) view every other complex has the same R-wave height, almost like a slight electrical alternans.... Is this what you are referencing?
BEorP Posted July 24, 2013 Author Posted July 24, 2013 On the bottom lead (I assume lead II) view every other complex has the same R-wave height, almost like a slight electrical alternans.... Is this what you are referencing? Yes, that is what I was most curious about. The irregularity in the rhythm is very minor, but very significant to the overall interpretation. The differing R-wave heights is obviously pretty minor compared to the example ECGs of electrical alternans floating around there (and clinically we wouldn't be expecting a spontaneous massive pericardial effusion in this patient), but I guess ultimately my question is when a finding like this becomes significant enough that it is worth reporting. If I'm not just seeing things (which I'm not entirely convinced of yet), I guess the next logical question is whether we can speculate as to the possible mechanism in this case. From the little bit that I have read, it seems like there is debate over the causes of this in patients without pericardial effusion (but then again the ECG book recommended by ERDoc hasn't arrived yet so maybe I need to check there once it does).
Mateo_1387 Posted July 24, 2013 Posted July 24, 2013 I am interested in knowing its significance too. Also, my interpretation of the EKG would depend if it is electrical alternans or not. I'm leaning between sinus tachycardia with electrical alternans, or sinus tachycardia with premature escape complexes, and I a few others. A-fib is one on the list, though this EKG sample has a pattern, every other complex group has the same R-R wave distance, leading me to think its not A-fib. So, what was the answer given with the sample?
paramedicmike Posted July 24, 2013 Posted July 24, 2013 I see what you're talking about and didn't notice it the first time. I'll do some reading, too, and see what else is out there.
BushyFromOz Posted July 24, 2013 Posted July 24, 2013 Ah, i didn't notice that.... attempts to stab my calipres into the computer screen and measure things have failed........
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