88 year old female: Weakness

This great case was submitted by Vince DiGiulio, EMT-CC; we highly recommend you read his wonderful blog The Medial Approach to Emergency Medicine. As usual, the case has been altered to protect patient and provider privacy.

You're working triage in a busy urban ED when an 88 year old female is brought in by her family. She is in a wheelchair and appears lethargic.

When you introduce yourself she comes around and is able to answer your questions, albeit with some hesitation. Her family reports that she is independent and lively at baseline and are concerned she is having a stroke.

You move her into a triage room and grab a set of vitals. Her breathing appears unlabored with an irregularly irregular pulse at her radials. You ask an ED tech to join you to help with acquiring an ECG.

  • Pulse: 80-100, irregularly irregular
  • BP: 122/83, auto-cuff
  • Resps: 22, unlabored, clear bilaterally
  • SpO2: 92% r/a
  • GCS: 14 (E3 V5 M6)
  • LAPSS: Negative

The ED tech runs a strip from the monitor after switching to Lead I as Lead II had small complexes.

All Over the Map - Rhythm Strip

You call back to the charge nurse and ask for a bed assignment and wheel the patient back with the help of the ED tech. In the room a 12-Lead ECG is acquired while a complete history is gathered.

  • PMHx: hypertension, hypercholesterolemia, Type II diabetes
  • Meds: lisinopril, Lipitor, glipizide, ASA, and a multivitamin
  • Allergies: PCN and Sulfa
  • Last In's/Out's: normal lunch, vomiting during the afternoon
  • Events: progressive lethargy and weakness after vomiting in the afternoon

The RN hands you a copy of the 12-Lead while she updates the electronic chart.

All Over the Map - 12-Lead

Given the 12-Lead you decide that a Lewis Lead should be acquired, as it may give additional insight into the underlying rhythm:

All Over the Map - Lewis Lead

The ED physician walks into the room and asks you one question, "does she has a history of atrial fibrillation?"

  • What is this patient's rhythm?
  • What are some potential causes of our patient's rhythm?
  • Does the Lewis Lead offer any potential insights into our pateint's rhythm?
  • Would this information change your treatment decision?


  • deezy says:

    Rhythm: A-Fib with 2nd degree type 2 AV block — The block can be noted by the dropped complex in the lewis lead, while a P wave is present. Left axis and no ectopy. ST elevation noted to inferior leads in multiple complexes, most prevalant in the first and third where the complexes are isoelectric with minimal wander.
    Lewis Lead: I wish I was more well versed on the Lewis Lead, and the link doesn't really offer much other than how to do it. With that…If I were a gambling man, I'd put my money on new-onset AF.
    Causes: She's old….
    Treatment: Coagulation studies and cardiac workup.

  • Darren says:

    I don't think it's a fib.  The Lewis lead decreases the effect of the QRS complex and enhances the atrial activity.  In this example, you can clearly see P waves associated with each QRS, thereby ruling out a-fib.
    Having said that, I'm not exactly sure WHAT the rhythm is!  I'm leaning toward wandering atrial pacemaker, because of the different shapes of the P waves.  There also appears to be a nonconducted P wave in the Lewis lead.  I would say 2nd degree type 2, were it not for the varying P waves and PR intervals.
    In the 12 lead, there appears to be some slight elevation in the inferior leads with (very slight) reciprocal depression in V6.  I don't think it's enough to say a STEMI, but I think an exploratory cath would be reasonable considering presentation.  Also noted slight left axis deviation.
    So, potential causes: AMI, electrolyte imbalances, medication side effects or reaction.
    It would definitely change treatment as far as medications are concerned.  I would love to see some lab work, including cardiac enzymes and a metabolic profile.  She obviously needs oxygen as well.

  • Darren says:

    In addition, thanks for posting the Lewis lead mention and link.  That was my first encounter with it, and I've had several patients with rhythms that I didn't think was a-fib, but had to call it that for lack of options.  This is a quick and easy way to figure out what the atrium is truly doing.  I'm still not sure that I DO know, but I sure could see what the atrium was doing a lot better with the Lewis.

  • On this 11th anniversary, just wanted to say “thanks” to all the EMS providers and firefighters who serve on the front lines of public safety and emergency services.

    The 12-lead ECG and both rhythm tracings are displaying multifocal atrial tachycardia (MAT) with mostly a 1:1 A-V conduction.  On each of the three images, there are occasions of varying A-V conduction which is sometimes observed in MAT.  There is also a left axis deviation (LAD).  In the precordial leads, there is clockwise rotation and dominant S-waves all the way from V1-5.  It's not until lead V6, that the QRS complex is equiphasic.  There's relatively low QRS voltage in the limb leads and in V6.      

    Combining the two statements of atrial fibrillation AND second-degree Type II A-V block are incompatible.  That fact that there are P'-waves effectively excludes any possibility of this being atrial fibrillation.  The nonconducted atrial impulses are not due to any type OR degree of failed conduction (i.e., A-V block).  Genuine Type II A-V block (which this is not) is almost always seen in the presence of bundle-branch block and is an unequivocal indication for implantation of a permanent pacemaker.  The atrial impulses that are not conducting have the same clinical significance that nonconducted PACs have.  Here, a couple of the atrial impulses are perched on top of the T-waves when the ventricular tissue is in absolute refractory period (ARP).  It is physiologically normal that the atrial impulses do not conduct because the ventricles have not finished repolarizing yet.  Had the atrial impulses arrived at the ventricular tissue slightly later, then they would have conducted.

    MAT is most commonly associated with chronic obstructive pulmonary disease (COPD) in addition to associated lung disorders:  far-advanced pneumonia, chronic bronchitis, emphysema, etc.  It can also be seen in digitalis intoxication as well as other diseased states.

    Digitalis is not listed as one of her active medications nor is her ECG suggestive of digitalis effect or toxicity.  There is no mention of COPD in her PMHx, however her ECG vaguely suggests some telltale signs of pulmonary disease.  It would be interesting to know if she ever was (or still is) a long-time smoker.  I think this patient might fall under the category of:  “other diseased states” as the cause of her MAT.    

    In the Lewis lead rhythm tracing, the 8th beat is probably a junctional escape beat that is dissociated from an atrial impulse.  The relationship between the P-wave and the QRS is foreshortened.

     MAT is categorically misinterpreted (by the ECG machine’s computer) as atrial fibrillation so it is no surprise that the computer did not make the right statement here. (1)  If there is one arrhythmia that is completely reliant upon the eyes of the human reviewer, it is MAT.  The computer will get it wrong every time!  I know from personal experience that each time I’ve seen a 12-lead ECG of MAT, the computer has interpreted it as atrial fibrillation with rapid ventricular response.   Instead of calling it MAT, some authors still prefer the older terminology of chaotic atrial tachycardia or rhythm.  Quite often, the cardiologist does not recognize MAT either and may be influenced by the computer's statement of atrial fibrillation.

    (1)  Multifocal atrial arrhythmia–a frequent misdiagnosis? A correlative study using the computerized ECG. P P Varriale, W W David and B E BE Chryssos Clin Cardiol 15 (5):343-6 (1992) PMID 1623654

  • Christo says:

    Roger, thank you for your reponse.  Is the diagnostic criteria for MAT the same as other tachy arrhythmias, in that they are at rates greater than 100 bpm? If that is the case is the rhythm this patient presents with know as Mutlifocal Atrial Rhythm, due to the rates less than 100 bpm?

  • johnny says:

    The P waves are Multifocal, but not that important in my eyes. Its not MAT bc the rate isnt fast enough. 
    2nd Degree Type Two .. Dropped beats with beautiful P waves shown. 

  • Lindsey says:

    A fib and threw a clot to the brain that is possibly causing her lethargy and change in mental status.  Family always has some good input!

  • Lynn says:

    Second degree, Type 2 is what it looks like to me folks. Also, the pt is hypoxic. Geriatric patients don't usually perfuse as well as younger people, and this lady has a reason to be lethargic-as well as nobody has mentioned whether or not a finger stick has been done. It does state that she was more lethargic after vomiting-which is dangerous in a diabetic-period. Looks like she needs a good total assessment, possibly placing a pacemaker to correct the rhythm. It's not A-fib, due to the fact that you can definitely see p waves, and the rate is not tachy. She could also be experiencing a non-STEMI….. Seen that happen before with the elderly. Could be that she's compensated for a while not perfusing. Just sayin'..

  • Dominick says:

    While it is theoretically possible to have the underlying pathophysiology of a Mobitz AV Block and atrial fibrillation, it is impossible to make this determination from any EKG. Also, P-waves and Atrial Fibrillation are mutually exclusive. Taking it to the absurd, it would be like saying Normal Sinus Rhythm with Ventricular Fibrillation.
    I would be inclined to disagree with the statement that the patient is hypoxic. Based on the sea level oxyhemoglobin disassociation curve, a pulse oximetry of 92% equates to about 80 TOR, which is the lower margin of appropriate oxygenation.  Borderline hypoxic, perhaps. Keep in mind, we don't know this patient's location and altitude and higher elevations 80 TOR can equate to higher pulse oximetry readings. Also, pulse oximetry readings have a margin of error of +/- 2%. While we cannot definitively say she's hypoxic based on the information presented, any prudent provider would apply supplemental oxygen to attempt to rule out hypoxia as a presenting problem.
    I'm going to agree with this not being atrial fibrillation (confirmed via S5). I don't see this as being any type of AV Block. The P's without QRS response, to me, appear more consistent physiologically, to non-conducted PACs. If we were to capture a minute of strip, I'm willing to bet that there's a good probability we'd capture an abberently conducted beat consistent with Ashman's phenomenon. This is more from the rate variability and refractory periods than from an AV block.
    MAT seems to be the most appropriate diagnosis here. There appears to be several different P-wave morphologies with a slight variation of PRI. The atrial rate, conducted or not, is tachycardic, meeting the tachycardia criteria of Multifocal Atrial Tachycardia.
    There does appear to be some elevation in the inferior leads. While it may not be enough to meet STEMI criteria, it does make one HIGHLY suspicious of myocardial event. Especially if you consider the elevation in relation to the actual size of the QRS complex.
    My hunch is that this lady, at some point in the not too distant past, had an acute myocardial infarction as a result of occlusion of the RCA. This occlusion also could have disrupted bloodflow to the SA node, resulting in the formation of several ectopic atrial pacemakers in the form of MAT. Most of this is purely speculation at this point, but it seems a likely possibility.
    Great EKG!

  • Elaina says:

    Multifocal atrial rhythm.  Some blocked PACs are present.  This could be pt's usual rhythm, or it could be a result of an electrolyte disturbance (pt was reported to have been vomiting).  Definitely need to check electrolytes, and replace as needed.  She may also need some fluids.  Otherwise, pt is hemodynamically stable, so this rhythm wouldn't really require any other immediate treatment, other than determining and correcting the underlying cause.  Pt is a diabetic, so a blood glucose should also be checked as a possible cause of the altered mental status.  She should also have her head scanned … just because the rhythm isn't atrial fib doesn't mean CVA is ruled out. 

  • Luke says:

    Multifocal Atrial Tachycardia….MAT!!
    P waves morphing >3 and varying P-R intervals.  
    HR < 100

  • Jolene says:

    Sick sinus syndrome, due to age. Be prepared to pace, provide supportive treatment until a pacemaker can be put in.

  • arnel says:

    There seems to have an irregularly irregular narrow QRS rhyhtm with P waves of different morpholgies and the PRI's seems to vary. There is low voltage limb leads with upright P's in lead I with no Q waves and loosing the R wave progression as we go towards the left precordial leads.  
    This I think is multifocal atrial rhythm (AKA wandering atrial pacemaker) / multifocal atrial tachycardia (MAT) for > 100 bmp. I would like to share this link from Drl. A Goldberger – http://physionet.org/challenge/2001/. They did a contest somewhere in 2001 on predicting paroxysmal AF/AFl. As per experience, this rhythms will convert to AF also most likely the echo of this one will reveal left atrial enlargement. 
    So for the sake of management, I have seen no article/study to for MAT intervention so there is a need to catch when this one converts to AF.

  • Mark Younger says:

    Very good example. My only comment would be where the illustrator drew in I, II, and III over the new vectors. This is incorrect. Once you move the electrodes, those vectors no longer are I, II, and III even if you use the same electrodes. This is confusing to the student. Lead I is always 0 degrees on the frontal plane, lead II always +60 degrees and lead III always +120 degrees. Other than that, this is a good example.

  • Christopher says:

    When you move the electrodes for an S5 or Lewis Lead, what do you select on the monitor if not I, II, or III?

  • Mario says:

    MAT InF changes

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