Odd EKG, any suggestions?

[Reddfrogg]

I'v been a medic for nearly 20 years, but I ran across a rhythm recently that I can't really identify. At first glance It looks like a A fib with bradycardia, rate in the 40s to 50s. But there are definite P waves, which are irregular, and seem to march through the complexes. The QRS complexes are are irregular and 0.172mm wide. Has anyone ever seen something like this?

[paramedicmike]

What else was up with the patient? History? Meds? Symptomatic?

[scott33]

12 lead?

[HellsBells]

Looks like a 3rd degree block, judging by the bottom lead

[scubanurse]

Would be nice to see a larger portion of the EKG and a 12-lead.

[paramedicmike]

Looks like a 3rd degree block, judging by the bottom lead

Based on what's there I kinda' thought the same thing but it's all too irregular.

Would be nice to see a larger portion of the EKG and a 12-lead.

Agreed.

[wrmedic82]

Id need a longer strip to be sure but it kinda looks like a mix between 2 rhythms: second degree type 1 and a atrial tachycardia with a block. I cant say 3rd degree because it looks like some of the Ps are actually conducting the QRS. I wouldnt doubt that this Pt is going to go into a fib or a flutter at some point soon. I actually have a good strip of an atrial tach w/ a block. i will try and dig it out later. 

As far as treatment, I would treat symptomatically.