All done? Good, lets get started!
I apologise in advance to those who know what I am talking about, but I am assuming that not all of my readers have a working knowledge of fairly advanced ECG interpretation, therefore I am going to do a little bit of teaching with this one.
So here is my thought process for this ECG:
At first glance, I initially thought it was a third degree block. The widened QRS complex`s (The red arrow) were obviously ventricular in origin and coming at the slow rate that you could expect from a ventricular escape rhythm. However, when I looked closer I couldn’t see any P waves, therefore I cannot distinguish if there is any correlation between P waves and QRS complex`s. Is the because of AF? again, unsure as there was artifact, but there was something else that needed investigating first…..
Next I moved onto the funny little squibble before the ventricular beat (The blue arrow). That certainly doesn’t look like a P wave, but more like a low voltage RSR wave followed by a small T wave (The yellow arrow). If that’s the case, then we are looking at a normal beat, ectopic beat…..normal beat, ectopic beat – therefore its a ventricular bigeminy with a background bradycardia. Once you look at the blue arrows as the patients background rhythm you can then scan ahead and see that it is irregularly irregular, therefore the classic definition of AF comes to the front:
“any irregularly irregular rhythm with no discernable P waves is AF”
What some of you have been calling a missed beat (the green arrow), is actually where the bigeminal ectopic would be, but it just hasnt come in after that particular RSR complex.
So put them all together and you have an absolute bradycardic AF with ventricular bigeminy.
That doesn’t however, explain how a elderly gentleman can tolerate such a bradycardia. Amazing!
Congratulations go out to SJMedic who got the correct diagnosis from the first ECG!! – Clever clogs!
I also tend to agree with TOTWTYTR in his comment:
“What’s important is not the rhythm per se. It’s how the patient presents to you”
This is very much a ‘nice to know’ rather than a ‘need to know’. As long as who ever turns up for this gentleman recognised his severe bradycardia and acted on their findings, then he would be treated appropriately.
I checked up on him in the hospital a couple of days later and had a chat with the consultant looking after him who confirmed my diagnosis of the ECG, and informed me that the plan is for him to be fitted with an internal pacemaker as soon as possible.
Told you it was a good one!!
SJMedic, here is your Mars Bar!! :
I have really enjoyed doing this. If any of you have any interesting ECGs that you want to share with my readers, why not scan and email them to me at firstname.lastname@example.org, with a little history of the patient (all identifiable details changed please) and I will post them so we can all learn something from each other.
Just an idea!