ECG interpretation

[rariel]

I graduated last June with my BSN and decided in December to get an advanced nursing certificate in critical care (required in Canada to work in critical care). I just finished my first clinical and there is a required ECG assignment to go along with it. I need some feedback on my answer. I want to say this is a 2nd degree AV block type I but there is no non-conducted p wave present as far as I can tell. Am I missing something here? I keep going over it again and again, but can't come up with anything. I don't need the answer but some help to point me in the right direction would be helpful.

Atrial Rhythm: _____ Regular X_Irregular
Ventricular Rhythm: ___Regular _XIrregular

Atrial Rate: 50
Ventricular Rate: 50
P Waves: present positive preceeding

PR Interval: 0.2 -> 0.24 -> 0.28 sec (then dropped beat but no non-conducted p-wave)
QRS: 0.12 sec
AV Conduction: 1:1

QT Interval: 0.4 sec
ST Segment: _____Isoelectric _____ Elevated X Depressed

T waves: _____Positive X Inverted _____Flattened ____Biphasic

Interpretation:

Anticipated Interventions: ???????

[dianah, ASN]

It would be helpful to see the rhythm strip.

Are you sure this is not atrial fib?

[Susie2310]

Without seeing the EKG rhythm and knowing the patient's clinical condition it is at best a good guess, but just from the information given I would agree with 2nd degree AV Block Type I, and possibly an MI. It would be helpful to know if Troponin labs were done and what they showed. Second degree AV Block Type I can show P waves marching through the QRS. What symptoms were the patient having? The ST depression and inverted T waves lead me to think of cardiac ischemia, which could due to the bradycardia or could also be due to an MI.

[rariel]

I put the rhythm strip on there no sure why it didn't post.

[rariel]

Hmm...I see the strip when I click on the post not sure why it's not showing up for everyone else.

[dianah, ASN]

I couldn't see the link after I clicked on it.

Says "Error," and it wanted me to sign in?

Yup, try again with clear head!

appreciated Susie's comments!

[rariel]

Maybe that will work. I'm still stuck on the damn thing. I feel like it's super obvious what it is and I'm thinking too hard. It's an irregular rhythm with a missed beat. I'm now trying to figure out if the slight dip is a biphasic T-wave (prolonged QT) or just normal and I'm imagining things.

This is just an assignment of rhythm interpretation. There are no corresponding labs or assessment data. They aren't looking for the why of the rhythm just what is is and then I have to include the interventions. I can get the interventions if I could just get over this brain block.

[dianah, ASN]

On cursory glance, looks like sinus bradycardia with first degree AV block (PR is just over 0.20 or four boxes) and a sinus block.

[DaveICURN]

With these lines in mind, it seems that the strip provided doesn't fit. The measurement on the info provided shows a gradual elongation in the PR interval from .20-.24. This would imply a Wenkebach. However, there is no P wave preceding the pause. So it would appear that there is a pacemaker, SA node, issue. This may explain the bradycardia and the heart block.

1. Get a 12 lead EKG

2. Might administer Atropine to increase HR and see if further cardiac issues arise.

I for one am interested to see what the correct answer on this test is.

Good Luck!

[Susie2310]

I'm coming up with Type II Second-Degree AV Block. This rhythm could lead to cardiac arrest. The patient's heart rate is 50 bpm. As I'm seeing it, the PRI appears to be constant and not prolonged - there is no progressive prolongation that one would see in Type I Second-Degree AV Block, and the PRI is not prolonged > 0.20 seconds (5 small squares) which one would see in First Degree AV Block. After the third QRS a P wave is not conducted, so no QRS follows. The PRI that follows next does appear a bit shorter than the others. I think this rhythm could explain the ST depression and T wave inversion; the patient could be experiencing myocardial ischemia, and would likely be symptomatic with chest pain, shortness of breath, and decreased LOC. The patient could also be having an MI. For Type II Second-Degree AV Block I believe the ACLS algorithm for symptomatic bradycardia says Dopamine or Epinephrine infusion while the patient is prepared for pacing. Atropine should not be used as it won't work for this rhythm, and pacing is required.

[hawaiicarl, BSN, RN]

Sinus pause. Do not treat with anything.

Cheers

[Mavrick, BSN, RN]

I would call this Sinus Arrhythmia (probably respiratory related) in the setting of sinus bradycardia. There is no "dropped beat" as there is no "p" wave. There is also no AV block as there is no "p" wave to be blocked.

I see this a lot in PACU. People are just waking up and taking slow breaths with a HR in the 40s and 50s. As they get more awake their rate picks up and the slight variation between beats is not so pronounced. You really need a longer strip with concurrent clinical assessment. (i.e. the thing happens with every inspiration)

No zebras here, move along.