What’s the heart rhythm?
*** Update 12/28/09 ***
Hint: These are certainly atrial complexes (blue arrows) but are they P-waves?
I believe it's multifocal atrial tachycardia. I was trying to talk myself into some sort of block due to the extra P waves, but I think that the varying P wave morphology (and varying T wave morphology because of buried P waves), varying PRI in spots, and varying R-R in some spots makes MAT a better choice.A 12 lead would be nice to look at here (especially V1).
Long time lurker, first time replyer:I'm seeing wide QRS complexes and thinking it's an intermittent complete AV block.
I too would love a 12L.I've got three guesses:- Wenckebach (2AV Mobitz I) conduction w/ a variable drop rate. This screen is small, but I swear the PRi elongates before dropping.- AV dissociation, atrial rate ~200, accelerated junctional rhythm. If I'm not seeing elongation, maybe I'm seeing dissociation.- WAP w/ blocked conduction through the AV node for those hanging P waves.Regardless, I'm thinking there is some pathology creating this that I should seek out. Rate appears appropriate, so I'm thinking the pt is probably hemodynamically stable. Rx should probably be "treat the patient not the monitor" 🙂
@Billy – Sorry, bud! No 12-lead ECG for this one! @Scott – Thanks for reading my blog! I'm glad you left a comment. I agree the complexes look a bit wide, but it's difficult to say whether or not they are 120 ms. I'm not sure it's a complete AV block, but I do think there's variable AV conduction! @C.Watford – I've spoiled you guys with 12-leads! I'd like to see if anyone revises their guess based on the graphic I provided.I'll give you another hint. The patient was taking an antiarrhythmic that slowed down his atrial rate.Tom
I'll be totally wild based on your hint here and guess that this is some kind of atrial flutter.I'll admit that I would never call it that based on this strip without other info added.
Ding! Ding! Ding! You get the cigar, Alex. This is a case of atrial flutter with variable AV conduction and an unusually slow flutter rate. Good job!Tom
Bah, the unusual rate for the waves made me completely leave out a-flutter. Maybe some better PRi scrutiny, as it appears shortened in some. Good strip!
Damn. I was thinking this was flutter until I read the comments, especially by C. Watford, so I felt humiliated and waited to see how it turned out. You have to admit, Watford is usually bang right on!
Oh, yes. He is surprisingly strong with the force for a first-year paramedic! :)Tom
Definitely a-Flutter! Definitely not WAP: IF they were p waves, there were not 3 or more varying morphologies. I watch about 50 rhythms a day all day as a monitor technician…this stuff's groovy! glad you have a spot on the net for this, thanks!
Anonymous – You're welcome! I recorded this many years ago when I watched 32 rhythms all day as a monitor technician! :)Tom
Well i was thinking about atrial flutter from the begining- the ECG shows in some part the classical tooth like apperance of the P wave which favor the diagnosis , but was quite confused from the answers of my collegues that's why i prefered to wait !!!! May i ask what is WAP reffered to ?? Very interesting challenge and ready for the next one ..Many thanks
You're welcome, Dr. Hillis! Since this was well received, perhaps I will do a new rhythm challenge each month.Tom
Atrial tachycardia with variable AV block – classic presentation of digoxin toxicity. Was he on digoxin Tom?
If it was CHB you would expect the escape rhythm to be regular; the pauses suggest AV conduction.
atrial flutter with varaiable conduction and bundle branch block
I was leaning to aflutter with variable block, too fast and not regular for Heart Blocks any medication history
Mark P. –
I regret that I don’t remember any details about the patient. This was recorded on the Critical Care Stepdown unit back in 1997.
I’ll try to put this to good use immidetaely.
MCL-1 can be very useful in this situation
This is atrial tachycardia with variable conduction
I believe the underlying atrial rhythm is a multi-foci firing (I.e. wandering atrial pacemaker) with a Mobitz type II block. The PRi is variable but consistent with an WAP rhythm but the dropped beats are due to the very sick AV node. Looks very similar to a COPD pt I had who had a prox LAD occlusion. Good strip!!
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