Atrial Flutter vs Atrial Tachycardia with AV block - page 2

by ChaseZ

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I am a BSN student currently working as a monitor tech (Also an EMT). Lately I have noticed that many providers (Medics, RNs and even some MDs) just label any rhythm with multiple P waves Atrial Flutter. The way I was taught was... Read More


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    Also it seems a lot of people put so much faith in the EKG's interpretation of rhythms. It is so frustrating trying to explain to someone that a rhythm is clearly junctional even though e EKG says A fib.
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    Cool Chase. My manager in my CVICU fellowship classes always told us to cover up the machine's interpretation and make our own diagnosis. Many many many people go off the machine's read, especially outside the ICU. This pertains mostly to 12 leads. That's probably bc most don't know how to read 12 leads.

    Off topic, if you are going to work cardiac (even telemetry) you must learn to read 12 leads. Lets say you have a pt with active worsening chest pain and you get an EKG, but don't know how to read 12 leads and the Intensivist tonight is not available bc she is intubating someone downstairs. Is your pt going to have a massive MI bc no one can see and interpret the large ST segment elevation in V1-V3? No, you are going to be prepared to start therapy according to your facilities protocol. Who is MONA?
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    I am a total nerd when it comes to 12 leads, whenever I am bored I usually browse through the various EKG blogs online and brush up on my interpretation as well as read through my growing collection of cardiology books. On a side note "EKG for Emergency physicians" by Mattu is a fantastic book for practice. Anyway in regard to your question if I saw ST elevation in V1-3 I would first double check lead placement (people just throw leads on a patient sometimes). Then go through the DDX and rule out pericardits, BER, etc and Check for elevation, reciprocal changes, Q waves, new BBB. Suspecting a septal/anteroseptal I would call a code STEMI based off my ECG findings and presentation. Get ready for the cath lab or thrombolysis. Oh and have the crash cart ready for if they go into a arrhythmia. As far as MONA goes morphine, oxygen, nitro and aspirin. You want to provide pain relief, get those arteries open and improve perfusion and oxygenation of the heart as well as decrease myocardial oxygen demand and afterload. And also prevent further clot formation.
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    What bothers me are the people who do not understand that not all MIs are the same. Like the person who sees ST elevation in leads II, III, aVF and grabs the Nitro because the patient is having a STEMI but fails to realize they are having an inferior MI with right ventricle involvement and destories their pressure. Oops
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    it does matter as with reentry loops, especially the aflutters, they can be easily fixed with an electophysiology intervention. a flutters are an "easy" one line burn. so heck yeah, i try to identify the specific rhythm because treatment is different if you are looking at options in an area where the ventricular rate is stable as well as hemodynamics.

    atrial flutter is easily cured, i can't imagine a cardiologist not caring either way, seems crazy to me.

    most cardiologists i work with don't call an ep specialist stat, but they will look at reentry loop treatment differently. when the patient is stable, you have this luxury though.
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    [quote=letschill;6706895]i would have to agree here, for sure. if we are talking about indistinguishable fast rhythms, most cardiologists are not so interested in the strip that they really care exactly what every 6 second strip indicates (because some folks' rhythms change that frequently). they mostly care if the patient is symptomatic (low bp, diaphoretic, chest pain, dizzy) or not.


    have to respectfully disagree here. any doc can treat an unstable patient looking at a six second strip. any acls certified person can as well.

    cardiologists look at the entire 12 lead as well as axis deviation, bundle branch blocks, transition as well as for electrolyte disturbances and hypertrophy in making treatment decisions.

    a stable aflutter is treated very differently than an atrial tach with a block. research aflutter ablations please.

    .
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    [quote=zookeeper3;6711229]
    Quote from letschill
    i would have to agree here, for sure. if we are talking about indistinguishable fast rhythms, most cardiologists are not so interested in the strip that they really care exactly what every 6 second strip indicates (because some folks' rhythms change that frequently). they mostly care if the patient is symptomatic (low bp, diaphoretic, chest pain, dizzy) or not.


    have to respectfully disagree here. any doc can treat an unstable patient looking at a six second strip. any acls certified person can as well.

    i think in looking at a stable pt, looking at the strip goes by the wayside for many cardiologists-as to nailing down a specific name for something unusual. it seems that the nurses are often way more anal about assigning name when the rhythm isn't standard, and the docs will chart a general description (atrial rhythm, ventricular rhythm, etc) rather than try to specify. unstable pt, whole different story.

    cardiologists look at the entire 12 lead as well as axis deviation, bundle branch blocks, transition as well as for electrolyte disturbances and hypertrophy in making treatment decisions.

    a stable aflutter is treated very differently than an atrial tach with a block. research aflutter ablations please.

    .
    it so depends on your pt population and possible underlying etiologies for aflutter. i have very rarely seen pt's go to ep lab (i have worked for 15 years and across the u.s.) for any kind of ablation. mostly it seems that the cards docs feel it wouldn't help (pt would quickly deteriorate back to their faulty rhythm). many cvicu pt's have post op atrial arrhythmias that are treated pharmacologically, or just expected to be in that rhythm short or long term. i feel that it so depends on your location across the country as well as md preference and pt population. no absolutes.
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    Do I distinguish between a tachycardic A-flutter and A-tachycardia with and AV block? - yes. On the monitor A-flutter is not always going to look like your textbook A-flutter. If you work as a monitor tech, you'll experience various degrees of every rythm you'll encounter. Is it important to distinguish between the 2? - only if the patient exhibits signs of hypoperfusion and is symptomatic. Treating the cause of the tachycardia is more important than knowing which of the 2 rythms the patient exhibits. Febrile? Pain? dehydration? Treat those first and if the patient is stable, there's no need to further any treatment based on those rythms alone as well as the patients clinical status.

    I guess your question is "why don't people know their rythms?" I presume? Probably coz they don't take the time to read them. In the case of the MD's mis-labeling rythms, they have their reasons.
    Last edit by Pheebz777 on Jul 22, '12
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    Quote from ChaseZ
    I am talking more about rhythms with a cotrolled ventricular rate as apposed to indistinguishable SVT rhythms. As far as people calling anything with multiple p waves A Flutter, I think if is just a lack of understanding of the patho involved in various rhythms (ie A flutter being a reentry loop in the atria vs accelerated firing of the SA node in A tach) . Not that they should know, to most people it really is not a concern as they just focus on identifying the basic rhythms and recognizing potentially fatal arrhythmias. I am not trying to knock on ER nurses but it seems I get these mix ups a lot. The other day I had an ER nurse report that a patient was " A flutter in the 40's"......turned out to be some beautiful 2nd degree type II. Here is an example. When in ER the rhythm had a 1:1 P:QRS but with a varying PRI, they called it Sinus Rythm. Once on our cardiac floor, the nurse noticed the 2:1 block and called it A Flutter. I personally charted it as Atrial tach with a variable AV block (Looks almost like an underlying Wenckeback). Not saying I am correct, just my interpretation, I am still fairly new. http://i204.photobucket.com/albums/b...8/a176fbd0.jpg Letschill, good point on the dig toxicity, I also think it is common in patients wil valvular disease.
    That doesn't look like atrial tach to me. The p to p interval is the same. I actually put calipers up to my screen and mapped it out. Sometimes its buried in the T wave, but its there. This is just Atrial Flutter.
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    I tend to agree with the OP interpretation, leaning more towards a block. I've seen patients with 3rd deg heart block with atrial and ventricular rates within 20 bpm of each other. Tends to make it look almost regular sinus minus some missed QRS and what appears to be irregularity. Looking at that strip, to me, it looks more like 2nd deg type I... lengthening PRS then eventually a PRS w/o a QRS. If the P intervals truly march out, maybe a 3rd deg block with atrial and ventricular rates close to each other. Doesn't look like typical A-flutter to me though.


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