Posted by: medicblog999 | August 29, 2009

ECG Geek 4

heart-angiogram-sd3453-gaWell, this is a interesting one!

Called to a 82 yr old man who had a fall at home and couldn’t get off the floor. This came through as a ‘Cat C’ response, so off I tootled without any lights or sirens. The address was local so it didn’t really make a difference with the travel time anyway.

When I got on scene, I was met by a carer who comes in each morning and evening to help Joe, get dressed and undressed as required. The carer told me that Joe had slipped off the chair when he went to sit down, but due to the fact that he had a ‘dodgy ankle’, he couldn’t get back off the floor and into his chair.

All seems pretty straight forward, yes?

Whenever I attend to this type of patient, I always have a quick feel for the radial pulse as I am having a quick initial chat about what went on. As I was asking the usual questions :

  • Can you remember falling?
  • Did you feel dizzy or faint before you fell?
  • Do you fall often?
  • Do you have any new pain that wasn’t there before you had your fall?
  • What is stoppping you from getting up?

As I felt his pulse, it was strong and regular but was a little slow at about 50 beats per minute. I asked to see his medication list and low and behold he was on a beta blocker which I assumed was responsible for his slow heart rate. It was still a little low for my liking, but as was asymptomatic (i.e. had no symptoms from the slow heart rate), I thought that with the help of the carer I would get him off the floor and back into his chair. This was achieved without any problems and all appeared tickety boo!

I started to formulate a treatment plan for Joe, based around him staying at home and getting a GP referral to check to see if his dosage of Beta Blockers needed adjusting. Before I placed the call, I completed the rest of my secondary vital signs.

I rechecked his pulse……………surely that’s not right?

I check again, then move to his other arm and check again.

Its slow……REALLY slow…… is he sitting up talking to me?

M999: “Are you okay Joe, do you feel dizzy?”

Joe : “No son, I’m alright thanks”

M999: “Really????”

His pulse was hovering around the 28 – 30 beats per minute mark!!

M999: ” Joe, I’m just going to do a quick heart tracing because your heart seems to be going a little slow. It may be just the medication, but I need to have a quick look see, is that Ok?”

I attached the four limb leads from the 12 LifePak 12. This is what I get :

ECG Geek 4

He has no pain what so ever, he doesn’t feel dizzy or light headed. He looks a little pallid, but is undergoing treatment for anaemia, so is that poor perfusion or just anaemia?

I request a Category A ambulance backup and explain what is happening, to which he shrugs his shoulders and says

“Right then, oh well…”

As I wait for the crew, I cannulate Joe and place him on some O2.  He is saturating at 94% on air, so a little more wouldn’t go a miss in this case. I stop and think about a little atropine, but the guideline is a little vague on when to give as it is based on the patient being symptomatic, however, I decide that there is no way I can send a patient to hospital with a pulse less than 30 beats per minute without trying to do something about it, and as I have already said, maybe his pallor is due to poor perfusion rather than his anaemia. I give 500mcg Atropine which stimulates a few extra beats for a couple of minutes, but he then settles down back to his 30 beats per minute.

By now the crew arrive and take over care of the patient who is then whisked off to hospital.

Now for the big question?

What is your diagnosis of the rhythm strip? I had to really look at this one to get my diagnosis and even then I wasn’t sure if I was right or not. I am an ECG Geek. Ive said it in the past, and if I don’t know or am not sure what I am looking at then I have to find out. A quick trip to the coronary care ward and a discussion with the Cardiologist proved my initial provisional diagnosis right.

What do you think?


  1. Just glancing at the ECG, I’m surprised the patient was near symptomatic!

    Just a guess (I’ve had no clinical training)

    AF with complete block?

  2. Good test, off the top of my head I agree with David. Could also be interference as oppose to AF?

  3. A true fascinoma M999!

    – appears to be a dropped QRS midway suggesting a 2nd degree block
    – PR interval appears to be constant so probably a 2nd. degree type II
    – baseline has some artifact so hard to see the p-wave from the dropped beat
    – Conduction delay or bundle branch block evident from widened QRS

    I KNOW you did a 12 lead at some point so can you share, us EKG geeks are curious!

  4. Ok had to have a real good look. Now my initial thought was a 2nd degree type 2 heart block. Then I really looked at it and then a crazy thought came in to my head. Is that a pacer spike prior to every p-wave? Is it a malfunctioning pacer? If I am right do I get a mars bar?

  5. All good guesses so far, Im not giving any hints yet as I want to see what the other regulars think of it without giving too much away!!!

    I told you it was an interesting one!

  6. I am no expert, in fact this problem made me realise I need to re-read some books. But I’m confused that these are the limb leads. There is a P-wave, but it seems to skip a beat. The complex is wide, indicating slow conduction, and there doesn’t seem to be a T-wave. Is it some form of hyper K+??

  7. actually make it a curly-wurly

  8. With out seeing a bit longer strip, it’s hard to know if the ventricular response is irregular or if you just caught it slowing down.

    There seems to be a P wave before each of the three QRS complexes. The wide QRS complexes, without knowing what his baseline QRS complexes are, would indicate IVR, but with the P waves I’d say not.

    I can’t put a name to this, so I’d just describe it.

    You don’t say what his BP is, but other than that he looks pretty stable. Well, if you can call this stable.

    Did you think about pacing?

  9. ECGs are not my strongest of subjects, but I’m going to agree with some of the guys above and say 2nd degree type 2 heart block.

    Or do I need to get my books back out and look at ECGs again…cardiology never was one of my favourites or strong points!

  10. I’d say our friend is about to wander into 3rd degree land. The “squiggles” prior to each p wave, and the one where the next complex should be could be a dying pace maker, or some kind of junctional escape beat trying to break through.

    I’m with Too Old on this one, no name to give, but certainly a clear description and capture any changes. If the beat is dropping regularly I’m curious to know why.

    I wouldn’t adenosine him, his problems are elsewhere, After basic interventions I would consider sedation and pacing, if the fluid bolus didn’t work.

  11. I’d stick with 3rd degree heart block…. The intervals between P waves (although I don’t think they’re proper ones… ) seems equal, but with no corellation to the QRS. Come on! Give us the answer 🙂

  12. Okay I’m at work now and have a hard copy of the strip and my co-workers are chipping in with their opinions and I’m starting to question my own theory of a probable 2-II AVB

    We all agree we would like to see a longer strip!

    The baseline does appear to have low amplitude pacemaker spikes but they are not mapping out as regular as you would expect – pacemaker failure or intermittant capture could be the problem; there’s one before each complex but not a complex after each one.

    My nurse (and self-proclaimed amateur cardiologist!) partner has given up, using the catch-all “looks like FLB’s to me” as he goes for a soda…

    You describe the reaction to the Atropine as:
    “stimulates a few extra beats for a couple of minutes, but he then settles down back to his 30 beats per minute”
    Atropine usually has no effect on a 3rd degree but I have seen it work on other blocks, I’m assuming the morphology did not change with this speeding up.

    Anyway, good case Mark and thanks for posting.

  13. My guess is that those are low-voltage QRS complexes, not p-waves, and that this is bigeminy. Possible beta blocker overdose, causing bradycardia, causing iritation to the heart, causing PVCs. He needs Glucagon, that’s why the Atropine didn’t work.

  14. Looking at the more clear strip, I’m inclined to agree with SJMedic. The small complexes look like the underlying rhythm. I still don’t see p waves, but if the he does have AF, then that make sense. I also suspect a prolonged Q-T interval. The PVCs aren’t, they escape beats because the intrinsic rate is so slow.

    Beta Blocker OD would be a good working Dx, so Glucagon is probably a reasonable approach.

    All things considered unless he is really unstable I’d wouldn’t be too aggressive in treatment. Then again, I tend to be a minimalist paramedic.

    Your partner is right, they certainly are FLBs. What’s important is not the rhythm per se. It’s how the patient presents to you.

  15. 2nd degree advanced AV block. Difficult to tell with the poor amplitude P waves. I don’t think it’s 3rd degree as the QRS are irregular and so are the p waves. Difficult to say with out seeing the the 12 lead. Have had several pts present the same way with ridiculously slow hearts but asymptomatic. If it’s less than 40 then they get atropine.
    As for pacing, it’s in our guidelines but as far as I’m aware there aren’t many services who have adopted it. We have the facility on our machines but they have been disabled. Our CCPs are getting it though.
    Was it a beta blocker OD? Although glucagen is not in our UK guidelines (I usually phone A/E & get the OK that way) for BB OD or life threatening anaphylaxis unresponsive to adrenaline it would be the next option after atropine failure as it raises cAMP. A bit like heineken beer, it reaches parts that other drugs can’t.

  16. […] ECG Geek 4 […]

  17. Having definitely not read the most recent post giving the answer, I’d say it was definitely bradycardic AF with ventricular bigeminy. Yup. Clearcut, only took about 5 seconds and I’ve never read an ECG seriously before, honest!

  18. I see rate 38-40, irregular, inverted p waves junctional rhythm, wide QRS equals bundle branch block…IV NS TKO , definately do 12 lead and would need to know BP…

  19. I see rate 38-40, irregular, inverted p waves junctional rhythm, wide QRS equals bundle branch block…IV NS TKO , definately do 12 lead and would need to know BP…

  20. I see rate 38-40, irregular, inverted p waves junctional rhythm, wide QRS equals bundle branch block…IV NS TKO , definately do 12 lead and would need to know BP…

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