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: ???????

[hawaiicarl, BSN, RN]

The problem with that being a sinus arrhythmia, is that that it isn't. Other than the dropped beat the R-R intervals are the same. In a sinus arrhythmia they would vary.

Cheers

[Mavrick, BSN, RN]

This is a strip of 2nd degree block. The "p" waves march out, even the lonely one. The "missed "qrs" causes an interval that is a multiple of the normal "qrs", in this case twice as long.

In the OP strip there is no dropped beat. ("p" wave without a "qrs" complex). Brackets show where a "p" wave would be expected in a second degree block.There is a significantly longer R-R interval between the 3rd and 4th complex but it is not twice as long, indicative of a missed beat. The other R-R intervals are slightly off, consistent with plain ole sinus arrhythmia.

This is a strip of sinus arrhythmia. Each "p" wave has a "qrs" complex with a consistent P-R interval. There is an easily seen longer R-R interval between the 3rd and 4th complexes. There is no lonely "p" wave.

[rariel]

I was overthinking it. I figured it out. It's sinus bradycardia with a sinoatrial pause. Thank you all for your insight and answers!

[Susie2310]

rariel said:

I was overthinking it. I figured it out. It's sinus bradycardia with a sinoatrial pause. Thank you all for your insight and answers!

Can you clarify if you are saying that this is the official answer provided by your course, or if you mean this is the answer you arrived at, or both?

[akulahawkRN, ADN, RN, EMT-P]

To me, it looks like a Sinus Brady with Sinus pause. Nothing complicated about it. This isn't any type II block as there's not a P wave without a QRS complex. All we're seeing is three normal beats, a pause and then two more normal beats after the pause. Unless the bradycardia is symptomatic, you don't need to treat it. Just doing a quick guesstimation, the heart rate is just under 60, however given the limited info of just a 6 second strip, the effective rate may actually be closer to 50. A sinus pause can be a very normal variant of normal sinus. What's interesting with this is the pause exactly marches out. If you measure from where the "missing" beat should be and where it picks back up again, there's no compensation for the missing beat. The SA node picks back up right on time/schedule.

[Mavrick, BSN, RN]

akulahawkRN said:

To me, it looks like a Sinus Brady with Sinus pause. Nothing complicated about it. This isn't any type II block as there's not a P wave without a QRS complex. All we're seeing is three normal beats, a pause and then two more normal beats after the pause. Unless the bradycardia is symptomatic, you don't need to treat it. Just doing a quick guesstimation, the heart rate is just under 60, however given the limited info of just a 6 second strip, the effective rate may actually be closer to 50. A sinus pause can be a very normal variant of normal sinus. What's interesting with this is the pause exactly marches out. If you measure from where the "missing" beat should be and where it picks back up again, there's no compensation for the missing beat. The SA node picks back up right on time/schedule.

Actually it doesn't. After the "pause" the 4th complex comes in 0.12 seconds earlier than a fully "missed beat" would. Sinus pause is defined as a pause greater than 2 seconds. That's why I believe it to be a respiratory variant.

[akulahawkRN, ADN, RN, EMT-P]

Mavrick said:

Actually it doesn't. After the "pause" the 4th complex comes in 0.12 seconds earlier than a fully "missed beat" would. Sinus pause is defined as a pause greater than 2 seconds. That's why I believe it to be a respiratory variant.

Good catch! Though I must say that I'm not going to use my calipers on my screen... might cause some, shall we say, damage to it. I would be more confident of it being a respiratory pause variant if we could see a longer strip to catch another pause and see if it coincides with a respiratory cycle.

[NiteNursee]

To have 2nd degree HB your atrial & ventricular rate would be different, atrial greater than ventricular rate. More P's than QRS's. Type 1 remember longer, longer, dropped is Wenkebach. Type 2 PR interval is consistent with each P that has a QRS. PR can be normal or prolonged length, 0.12 or more. It's just a dropped beat. Resp cause, could be called a if you want a name Sinus Arrhythmia. Treatment only needed if patient is symptomatic.

[richfield1977]

I have a Basic Arrhythmia competency test in 2 weeks. Any suggestions on where to get some information on that for studying, test format etc.?

Thanks

[MusicGuy]

On 7/16/2019 at 9:56 AM, richfield1977 said:

I have a Basic Arrhythmia competency test in 2 weeks. Any suggestions on where to get some information on that for studying, test format etc.?

Thanks

Skillstat!