Double 'P' waves?!?

[AZCEP]

So we are sure it's not an AV block, or Atrial flutter, or P-mitrale. Until a strip is posted, we are left grabbing at straws.

What is the P-P interval? Does it remain the same for every interval, or does it change?

What is the P-R interval? Does it remain the same as well? Is the R-R interval identical?

Is there a clearly defined T wave? Are you certain the "extra P" is not a U-wave?

What is the heart rate while this is happening?

[Dooger]

...Is it possibly a biphasic p-wave which would be indicative of atrial enlargement? There are biphasic p-waves that appear to be two p-waves side by side without breaking the isoelectric line.

Shane

NREMT-P

I'm checking into this and the p-mitrale route again... now that I have done a bit of research (thanks to you & ERDoc) I definately need to check the ECG (assuming I still have it) to see exactly what we're dealing with. I'm planning on doing a lot of digging tomorrow to find the strip for you, sorry, I should have done that before posting. It was one of those things that hit me while I was reading other posts & I wanted a bit of direction from your minds!

I have found a bit of information on interarterial blocks, which I wasn't sure was possible. Based on Dr. David H. Spodick's commentary it would seem that it is possible for completely seperate P-waves if the interatrial block is significant:

LA “strength,” as represented by LA kinetic energy (LAKE), progressively worsens as the interatrial conduction time increases (over a range of interatrial block from 120 to >200 ms), with an inverse linear correlation to LAKE. With a definitely split P wave (which is usually the case; relatively few are not clearly split) in interatrial block, an interpeak distance of ≥40 ms is an extremely specific sign of LA enlargement. [align=center:af4c4f2fc2]Italics added[/align:af4c4f2fc2]

[scope2776]

So we are sure it's not an AV block, or Atrial flutter, or P-mitrale. Until a strip is posted, we are left grabbing at straws.

What is the P-P interval? Does it remain the same for every interval, or does it change?

What is the P-R interval? Does it remain the same as well? Is the R-R interval identical?

Is there a clearly defined T wave? Are you certain the "extra P" is not a U-wave?

What is the heart rate while this is happening?

Yes, excellent questions, waiting for the answers, defiantly interested...

In your opinion were the waves more like p-mitrale or two separate waves?

How close were the waves to the QRS complex? (PR interval?)

Was there a negative component to the wave?

Did you check your lead placement and monitor settings? Just asking.....

Maybe a second degree 2:1 block, or for some odd reason i'm thinking LGL if they were really close to the QRS....

Could also be the result of an accessory pathway... antedromic reentry? Really just stabs in the dark at this point.

[Dustdevil]

Come on, guys! This is obviously PID. O2 at 6 or 15lpm, b/l 14ga saline wide open, cardiovert at 100 or 360, and haul ass to the LZ so the critical care medics in the helo can do an immediate ORIF enroute to the Mayo Clinic.

[ericenglund]

Come on, guys! This is obviously PID. O2 at 6 or 15lpm, b/l 14ga saline wide open, cardiovert at 100 or 360, and haul ass to the LZ so the critical care medics in the helo can do an immediate ORIF enroute to the Mayo Clinic.

I rarely "laugh out loud" when reading on the internet but after reading the posts you're mocking and then seeing this i got a good laugh in. Thanks.

However, does your PID protocol not mention narcan? you neglected it in your post.

[FireMedic65]

just to be a stinker, i have too seen something very similar to this, although my patient was not stable, and whatever the it was, it broke before we got to the ER. But from what i remember, it was a sinus tach with BBB, rate in the 130s, pt complaining of severe crushing chest pain, radiating to jaw and shoulder with weakness in the hand, bp was crap over nothing (62/p) etc etc... anyway, it was a classing text book sinus tach, except for the mysterious P wave, everything fell into normal parameters for it so be sinus, except, there was an INVERTED P wave .08mm preceding another up right p wave, followed by the QRS. The P waves appeared to be similar in shape. 12 lead showed a lateral wall stemi bout 3mm off baseline. i have the strip somewhere, ill have to dig it up for you all to see.

[Dooger]

However, does your PID protocol not mention narcan? you neglected it in your post.

I read that drinking an amp of D50 (preferably with pizza) might be benificial... as long as it doesn't go interstitial on ya!

[akroeze]

ORIF enroute to the Mayo Clinic.

Your flight medics do Open Reduction Internal Fixation? :?

[ERDoc]

All of these cross-references to other threads is really beginning to confuse me (it doesn't take much sometimes). Some people keep bringing up a LBBB, but let's keep in mind this is a 16y/o girl. The chances of her having a true LBBB, or an MI for that matter, are slim.

Edit: See, I thought I was posting in the thread about the 16y/o girl with the tachycardia. Go ahead and have a good laugh at my expense.

[Just Plain Ruff]

But doc, it could happen you know. Stranger things have happened.