Atrial Flutter vs Atrial Tachycardia with AV block

[ChaseZ]

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?

[LetsChill]

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.

Exactly. I'll applaud that response.

[kissafish4]

Yeah the only blocks atropine is usually used for is mobitz 1 or complete heart block. Wouldn't work for Second degree type 2. Chase I worked as a monitor tech for 12 years before going to nursing school and it really frustrated me when the nurses couldn't accurately interpret their own rhythms. Often I would receive patients from the ER with heart rates in the teens and low 20s where the nurse has reported "sinus brady" when they're clearly in a complete block. Everyone has their specialty and although every patient has a heart, not every nurse is a cardiac one.

[SpEdtacular, MSN, RN, EMT-P]

Always nice to meet another EKG nerd OP! :w00t:

My vote is for second type II or third degree (or some combination of the two) but there's a reason it's call interpretation, it can be very subjective and unless you're in the electrophysiology lab you may never know for sure. I think when deciding if something is A-flutter it's useful to see if there are distinctive T waves and whether there is a return to the isoelectric line because either of those things suggest something other than flutter. Differentiating the different atrial tachycardias can be helpful when trying to determine etiology and definitive treatment but usually with an acute onset the main concern is rate control so it doesn't really make a big difference and besides, there's always cardioversion!

We get some interesting interpretations from our monitor techs too: insert rhythm with "minipauses" is my favorite so far.

[SpEdtacular, MSN, RN, EMT-P]

An inferior wall or R sided MI isn't an absolute contraindication to using nitro however that being said it these infarcts require adequate preload to support R ventricular function. As long as you don't cause hypotension nitro can be useful but must be used cautiously.

[ChaseZ]

Thanks for all of the comments. Honestly, A fib w/ 3rd degree never really crossed my mind at the time. It does make sense looking back however I have never seen that before. Very interesting.

[AnnersRN]

The thing driving me crazy lately- 3x this year- an ER nurse and a 3rd year Resident telling me a patient rhythm was junctional in the 30's to 40's... it was clearly 3rd degree heart block. Actually had a small tiff with the resident until the Cardiology Fellow backed me up :)