Atrial Flutter vs Atrial Tachycardia with AV block

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

    • Yes

      76.19% 32
    • No

      19.05% 8
    • No clue what you are talking about

      7.14% 3
    42 Votes / Multiple Choice
  3. 29 Comments

  4. by   ChaseZ
    Sorry about the huge paragraph, not sure why it will not let me break it up? Maybe since I am on my Ipad
  5. by   missnurse01
    We often have cardiologists not know exactly what many funky rhythms are, and most only care if they have a b/p. If vent rate is high sometimes they give meds to slow it down to diagnose, but no one seems to treat differently
  6. by   Susie2310
    I am interested in your question, although I am not qualified to answer it. These are my thoughts though:

    I don't have an answer as to why one would label any rhythm with multiple P waves A-flutter.

    I am also not understanding why your being taught to distinguish between A-flutter and A-tach with AV Block would particularly assist you in determining if a rhythm is A-flutter (I'm not suggesting that there isn't a good reason you are being taught this, just that I can't figure out for myself what it could be). Perhaps an experienced critical care nurse can offer some insight (I am not a critical care nurse). From studying ACLS AHA Provider Manual 2011 and AHA online pre-course prep, as far as I can understand the rhythms you mention are quite different from each other, albeit they are both tachycardic rhythms.
  7. by   LetsChill
    Quote from missnurse01
    We often have cardiologists not know exactly what many funky rhythms are, and most only care if they have a b/p. If vent rate is high sometimes they give meds to slow it down to diagnose, but no one seems to treat differently
    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.

    Unknown fast rhythms here would get amio/cardizem/metoprolol/combo of these. Unless the pt is obviously symptomatic then you go with Adenosine. Period. Once you get the rhythm slow enough to distinguish it, more specific treatment can begin. If you can't get the rate down with all these meds and the pt is having chest pain and is SOB and diaphoretic, what do you do? Whats that red cart over there for?

    Remember that Atrial Tach and SVT (supraventricular meaning above the ventricle...isn't the atrium up there?) are extremely similar and are thus treated similarly. Atrial flutter is just a few atrial spasms away from atrial fibrillation, and the two rythms are treated nearly the same.

    Now, if you have a pt that truly has atrial tach with a 3:2 block, for example, the pt most likely has some dig toxicity. You probably won't see this rhythm too much (good to know, but, for most practices, not widely diagnosed) bc dig levels are checked often in the hospital for pts on dig and Digibind is quickly given if labs are critical, but this is also fairly rare.

    If the pt is on digoxin (without a recent lab level) and is having atrial tach with block (without PMHx atrial flutter, so not to confuse things), you will be able to proudly notify the cardiologist and give your SBARecommendation of a dig level, renal panal, mag and then perhaps Digibind.

    Keep on learning 'yall!
  8. by   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. Letschill, good point on the dig toxicity, I also think it is common in patients wil valvular disease.
  9. by   LetsChill
    For sure there is a block and I'd have to agree that it is definitely not atrial flutter. HR is in the 80s so not slow. Most blocks are treated similar. Watch for pauses, bradycardia, pt symptoms. You go Atropine, pace, Dopamine gtt.
    In nursing and medical practice, the charted rhythm is far less important than the patient. I'm sure that's obvious but in school the focus is learning the small differences according to the book. Atropine, pace, Dopamine gtt!

    Keep on learning y'all!
  10. by   ChaseZ
    Thanks for the input! I also just noticed you are from Saint Louis as well. Even if this patient went bradycardiac I think I would be hesitant to give atropine. Atropine will Increasing firing of the SA node leading to an increase the atrial rate potentially worsening the block while not guaranteeing any increase in AV condition. I think it could potentially have the opposite effect and cause the ventricular rate to slow? Just a guess. Some advanced blocks are rate dependent and will actually resolve with a controlled atrial rate and become disassociated with an increasing rate. Jumping right to pacing may be a better option if they were symptomatic Brady?
  11. by   Susie2310
    As I mentioned, I am not a critical care or ER nurse, but I have studied ACLS and 12 lead EKG's. I am certainly not an expert though. I find it difficult to comment on: 1) The rhythm the ER nurse reported, which then turned out to be something else 2) The rhythm in the ER that they called Sinus rhythm and was subsequently called A-Flutter by the nurse on the cardiac floor. I am not sure if you are referring to the ER nurse and the cardiac nurse interpreting the same 6 second strip differently, or if you are referring to apparent changes in rhythm that appeared on different strips. Let's Chill mentioned that some peoples rhythms change frequently. I feel I would need to see the strips myself before I could offer my opinion.

    The defining criteria on the EKG for A-Flutter, Type II Second-Degree AV Block, Sinus Rhythm, and A-Tach with AV block, are quite different as I understand them.
  12. by   ChaseZ
    Sorry I only have the single strip so I do not know if the patient's rhythm changed during transfer or not. However there were at times that the rhythm would appear to be 1:1 so I would not be surprised if it was called Sinus based off that. Atrial tach w/ block and Atrial Flutter can be very similar in presentation.
  13. by   ChaseZ
    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.
  14. by   LetsChill
    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?
  15. by   ChaseZ
    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.