Posted by: medicblog999 | April 27, 2010

ECG Geek 9 – Its Rhythm Time!

heart-angiogram-sd3453-gaThis edition of ECG Geek, comes to you courtesy of one of my readers, Arnel.

Arnel is a telemetry technician from the US and is as fascinated with ECGs as I am, and was kind enough to send in a collection of small rhythm strips from one patient which were taken over a 5 day period. Arnel has condensed them down to 10 short rhythm strips which I know will frustrate many of you, especially as there are no 12 lead ECGs and also no clinical history of the patient.

However, what Arnel is asking of us is to have a look at them and help him to understand what is going on with this patient. He asked two of his medical friends, one of which is an attending doctor in his hospital, both of who just stated that the patient had a 1st degree Heart Block.

I think there is a whole lot more going on than that.

But before you get stuck in, let me re-iterate. There is no clinical history to this patient, so yes I know that we are looking at ECGs in isolation without a clinical picture which goes against everything we are taught, but there is still a learning opportunity here. So lets go back to basics and think about P waves and QRS complexes.

So, you all ready?

Here you go, do me proud!

Rhythm Strip 1

ECG Geek 9.1

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Rhythm Strip 2

ECG Geek 9.2

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Rhythm Strip 3

ECG Geek 9.3

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Rhythm Strip 4

ECG Geek 9.4

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Rhythm Strip 5

ECG Geek 9.5

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Rhythm Strip 6

ECG Geek 9.6

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Rhythm Strip 7

ECG Geek 9.7

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Rhythm Strip 8

ECG Geek 9.8

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Nearly There….Rhythm Strip 9

ECG Geek 9.9

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And finally, Rhythm Strip 10

ECG Geek 9.95

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So thats your lot chaps!

10 rhythm strips, 1 patient, how many changes to the rhythm??

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Responses

  1. Wow there's a lot going on in those ECGs! Looks like at points they go into Wenckebach 2nd Degree block, sinus arrhythmia and possibly even short periods of AF! I haven't a clue!

  2. I see at least 3….1st degree block (strip 1), 2nd degree type I / wenkebach (strip 2 and 3) and junctional (strip 6 and 8.

  3. I think you are right. There are several rhythms present. If I were to use one term for this patient, I would go with sick sinus syndrome. Wenchebach seems to dominate. After a dropped beat, the PR interval is almost always very short. The problem is that it is not consistent. At least one of the QRSs, that appear to have more than one P wave, is not preceded by a short PR interval. At least one of the QRSs, that appear to have more than one P wave, is preceded by an unusually short PR interval – so short that it almost looks like a delta wave.All of this is much more interesting for the cardiologist, but the important thing is to treat the patient. I do not expect that this will produce significant symptoms in the patient, but patients do surprising things. We do not know the vital signs. We do not know if all of the beats produce pulses or if there is any difference in the strength of the pulses depending on the R to R interval, or anything else.Interesting strips. Thanks for showing them.

  4. There seems to be a lot going on at the AV node, with First Degree and Second Degree Wenkebach blocks, and some possible Junctional rhythms going on. I'm having trouble deciding how I feel about those strips lacking P's in lead II, where I'm thinking I see them retrograde in V1 and maybe they're just buried in the T waves in II. I'm also not sure what to make of the super-short PR interval during some of the beats of some of the 2nd Degree blocks, I could only imagine it being an accesory pathway of some sort but I don't really see a culprit delta wave or any other hints at WPW. Maybe Lown-Ganong, but that's only slightly more likely.On a non-rhythm note, the changing amplitudes of the QRS complexes caught my eye, and they are especially noticable in V1. I've heard of it before in tachycardias, but never really noticed it in a moderate rhythm, and it's not the alternating pattern of pericarditis (however there is a nice pattern). Possibly just a mechanical cause from breathing? Any opinions?

  5. i'm going to have to go with Rogue Medic on this one. I think it is Sick Sinus Syndrome as well. But here's something else to consider: Viral AV Node. I went into these rhythms after surgery at the age of 14. There were 2 considerations for me: The administration of Succ. for surgery or the fact that 18 hrs after surgery, I came down with Chicken Pox. Regardless, I now stay in a first degree block and when I get fall down exhausted, I go into the Second, which is corrected with a nap. I dont feel that there is enough history for this patient to guess as to WHY it is happening. Why was he in the hospital? Did he have surgery? How old is the patient? Another consideration: Is he an athlete? It just may be intrinsic pacemaker failure. I would be will ing to bet that if he had the E.P studies and an Echo, WPW would show up. Although there is not a definitive delta wave, I do see WPW.

  6. i always thought that sick sinus syndrome had to do with the rate more than the p-wave, e.g., tachycardia > brady > tachy > sinus > tachy> brady etc. perhaps i'm mistaken.However, while I agree that the first couple strips show 1st degree and 2nd degree Type I, i almost almost wanna say there's a 3rd degree in there (strip 5 especially — that looks like a p-wave in the S-T segment after the 4th QRS) as the p-waves seem to be marching out on there own. But then again, if this PT had a 3rd degree, i'm surprised that he made his way all to way to strip 10 to talk about it.Either way, I'm just making conjectures. The strips are great nonetheless — good teaching tools, and will go to show our young paramedic students that (yet again) Patients don't read the textbook.

  7. The first strip is indeed a 1st degree block, but the second is clearly 2 nd Degree Mobitz Type I Wenckebach. As are most of the rest. 8 might well be Junctional escape, but you can also make a case that it's a 1st degree with the P waves buried in the preceding T waves. I base that on the odd morphology of the T waves in V1. Then again, I might be reading more into the strip than there is. A 12 lead might tell us more, but the rhythm strips are enough to tell me that there is something going on that needs further investigation. For the record, absent some sort of critical clinical presentation, this patient, if in the field, would require a ride to the hospital and nothing more.

  8. i always thought that sick sinus syndrome had to do with the rate more than the p-wave, e.g., tachycardia > brady > tachy > sinus > tachy> brady etc. perhaps i'm mistaken.However, while I agree that the first couple strips show 1st degree and 2nd degree Type I, i almost almost wanna say there's a 3rd degree in there (strip 5 especially — that looks like a p-wave in the S-T segment after the 4th QRS) as the p-waves seem to be marching out on there own. But then again, if this PT had a 3rd degree, i'm surprised that he made his way all to way to strip 10 to talk about it.Either way, I'm just making conjectures. The strips are great nonetheless — good teaching tools, and will go to show our young paramedic students that (yet again) Patients don't read the textbook.

  9. The first strip is indeed a 1st degree block, but the second is clearly 2 nd Degree Mobitz Type I Wenckebach. As are most of the rest. 8 might well be Junctional escape, but you can also make a case that it's a 1st degree with the P waves buried in the preceding T waves. I base that on the odd morphology of the T waves in V1. Then again, I might be reading more into the strip than there is. A 12 lead might tell us more, but the rhythm strips are enough to tell me that there is something going on that needs further investigation. For the record, absent some sort of critical clinical presentation, this patient, if in the field, would require a ride to the hospital and nothing more.

  10. Question: Do you need to know the time of a strip or have a grid in the background in order to tell if a patient is in either brady, normal or tachy? In other words, can you look at a strip and tell what rhythm that patient is most likely in? NOT an exact heart rate but just an estimated rhythm? (brady, normal, tachy)….


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