Atrial Flutter vs Atrial Tachycardia with AV block

Specialties CCU

Published

  1. Do you distinguish between A Flutter and Atrial Tach?

    • 32
      Yes
    • 8
      No
    • 3
      No clue what you are talking about

43 members have participated

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 to distinguish between Atrial Flutter and Atrial Tachycardia with Av block. Does anyone else do this? Or is it just irrelevant to most providers except for cardiologist. Or maybe most people are not taught to distinguish the two just to make things easier. Anyway here is a break down of how I distinguish the two: Atrial tach w/ block : regular or irregular rhythm containing multiple distinct P waves per QRS. If there is variable block some QRS may only have a single P wave at times but usually a wandering PR interval. The atrial rate is 150-250. Atrial flutter: Usually regular rhythm contain multiple p waves per QRS however not distinct p waves, usually "sawtooth" or F waves. Atrial rate 250-400. Maybe I am off on my interpretation of this but that Is how I understand it. I am assuming in the pre-hospital world it would not make much of a difference and would be treated the same however in the hospital I would think it should be indentifed and is usually missed. Any input?

Specializes in Critical Care, Cardiac.

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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Specializes in Critical Care, Cardiac.

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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Specializes in ICU, ER, EP,.

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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Specializes in ICU, ER, EP,.
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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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.

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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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Specializes in ICU, CVICU, E.R..

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.

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Specializes in Cardiac.
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/bb170/chaserx8/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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Specializes in CT-ICU.

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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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
What bothers me are the people who do not understand that not all MEn 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 destroys their pressure. Oops

Not all inferiors are true posterior wall MI's.

The EKG strip? I don't believe that is flutter. There is no "saw tooth" configuration of the atrial activity and the atrial rate is not > 250. The atria and ventricles are beating independent of each other and doing their own thing.....it's AV disassociation, 3rd degree.

Now if cardiology wants to call it A.Flutter to not address that this is really heart block....ok by me.

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Specializes in CT-ICU.

Now if cardiology wants to call it A.Flutter to not address that this is really heart block....ok by me.

Haha! So true.

Yeah after looking at it with my fiance (CCU RN), we figured looks more like 3rd degree rather than 2nd... p waves march out, AV dissociation.

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Specializes in Cardiac.
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.
I'd agree with that. I initially felt it was this however, A flutter doesn't always present in the typical saw tooth fashion. In any cases, sometimes hard to deciper some rhythms due to rates.
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Specializes in Flight RN, Trauma1 CVICU STICU MICU CCU.

looks like 3rd degree.

All the conjecture about who misses or mislabels what is just ego-stroking nonsense. Watch your patients, watch your strips and watch your drips.

Being busy judging other providers will cause you to miss something.

Then who loses?

Your patient.

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