2 EKG strip questions

prep8611 · Jun 27, 2013

The first one actually looks like it trying to be atrial bigeminy.

CodeteamB · Jun 27, 2013

Ok, I agree it is hard to read photocopied strips,but here goes.

Strip one looks to me like underlying sinus bradycardia with PJCs (or PACs if we think the p wave is hidden in the preceding T). If you disregard the "extra" complexes (those without a clear p wave) the rhythm is regular and I see no lengthening pr interval.

Nothing new to add for strip 2.

MunoRN, RN · Jun 27, 2013

The first strip is bigeminal PJC's vs PAC's. A different lead might help settle which one it is, but without being able to discern PAC's (p waves) that may have triggered the early narrow QRS complexes you can't definitively say there are or aren't P's buried in that T wave, if there are no P waves prior to the early QRS complexes then they are PJC's.

The second looks to be SVT to NSR, if the compensatory pause was a bit longer I'd say it looks like what we often see when we give adenosine for SVT.

netglow, ASN, RN · Jun 27, 2013

[COLOR=#474747]ECG: An Electrocardiogram Rhythms Interpretation Guide By iAnesthesia LLC

I highly recommend this itunes app check it out. Live motion rhythms and edu.

brownbook · Jun 27, 2013

A cardiologist told me this many years ago and it applies here (and to many other areas of life, including non-medical situations.)

Ask 10 cardiologists to interpret an EKG and you will get 20 answers.

Sure you need to know the basics of EKG arrhythmias, but can go crazy in the details. Is this rhythm going to kill the patient in the next 10 minutes or next few days? Yes or no. If yes what interventions do I need to do.

nurseprnRN, BSN, RN · Jun 28, 2013

I'll bite.

1) Second-degree block with sinus bradyarhythmia and sorta-PACs (PR interval increased on "premature" beats) vs. serious variable sinus exit block vs. combination with Wenckebach-- group beats with increasing PR intervals and there may be a nonconducted P hiding in the T wave in spots- if you could determine that it would be helpful)

2) PAT/SVT, sinus pause, SR with borderline 1st degree block (hard to see)

Who wants to know? 12-leads would be helpful.

MendedHeart · Jun 28, 2013

Ok the first one confused me because a PAC needs a p wave before it and I dont see one unless its buried in the t wave which is possible but Ifvtheres no p wave its a PJC..its not a block..the PRI looks normal and there are not more p's then qrs's.

Im going with sinus arrythmia with pjcs maybe some pauses, or exit blocks but its hard to interpre so small and without calipers

I know I already said #2 is SVT..my first thought was..this looks like they had adenosine pushed and converted even though ive seen much longer pauses with that

Edit: sorry, didnt read all the above posted first.just pretty much repeated the same

bendyprissy · Jun 28, 2013

A cardiologist told me this many years ago and it applies here (and to many other areas of life, including non-medical situations.)
Ask 10 cardiologists to interpret an EKG and you will get 20 answers.
Sure you need to know the basics of EKG arrhythmias, but can go crazy in the details. Is this rhythm going to kill the patient in the next 10 minutes or next few days? Yes or no. If yes what interventions do I need to do.

I agree completely. As a previous Cardiology Tech who was a certified EKG Tech here's my interpretation:

Strip 1: NSR w/ PAC's. There is no P wave with a dropped QRS. If you have a QRS then the wave following it will always be a T wave.

1AVB - the distance between the P wave & the QRS will be longer than one big block (5 small blocks).

2AVBT1 - long, longer, gone - what this means is the distance between the P wave & the QRS will first be normal, then it will get longer, even longer, & then drop the QRS.

2AVBT2 - same, same, gone - the distance between the P wave & the QRS will be the same length, the same length, & then drop the QRS.

3AVB - the married couple (P wave & QRS) are no longer married (or together) - this means the P wave is doing its' regular thing, & the QRS is doing its' regular thing, but they're no longer doing it together. So you can literally take a piece of paper & put line marks between 2 P waves, move that paper along the strip & the P waves will be evenly spaced. Then you can do the same with the QRS's. But the QRS will not always follow perfectly behind the P wave. Between the P's & between the QRS's will be even but between the P & the QRS will be erratic.

Strip 2: Sinus Tachycardia with a sinus arrest into NSR. If the rhythm would have continued the way it was going without converting then it would have been SVT (camel hump) but it didn't & you can only count what it is actually doing, not what it might have done. When a rhythm starts off as one thing, has a pause, then starts back as a different rhythm then it is a sinus arrest.

Good book: EKG Plain And Simple 2nd Ed. by Karen M. Ellis

MendedHeart · Jun 28, 2013

Yea..I wasnt saying thats what was going on, just reminded me of it.

MunoRN, RN · Jun 28, 2013

I agree completely. As a previous Cardiology Tech who was a certified EKG Tech here's my interpretation:
Strip 1: NSR w/ PAC's. There is no P wave with a dropped QRS. If you have a QRS then the wave following it will always be a T wave.
1AVB - the distance between the P wave & the QRS will be longer than one big block (5 small blocks).
2AVBT1 - long, longer, gone - what this means is the distance between the P wave & the QRS will first be normal, then it will get longer, even longer, & then drop the QRS.
2AVBT2 - same, same, gone - the distance between the P wave & the QRS will be the same length, the same length, & then drop the QRS.
3AVB - the married couple (P wave & QRS) are no longer married (or together) - this means the P wave is doing its' regular thing, & the QRS is doing its' regular thing, but they're no longer doing it together. So you can literally take a piece of paper & put line marks between 2 P waves, move that paper along the strip & the P waves will be evenly spaced. Then you can do the same with the QRS's. But the QRS will not always follow perfectly behind the P wave. Between the P's & between the QRS's will be even but between the P & the QRS will be erratic.

Maybe I'm misunderstanding you, but a PAC refers to an early p wave, which usually conducts to form an early QRS (vs an unconducted PAC). No P wave with an early narrow complex QRS=PJC. If it appears to have no preceding p wave but a p-wave cannot be ruled out then it is a PJC, unable to rule out PAC.

Strip 2: Sinus Tachycardia with a sinus arrest into NSR. If the rhythm would have continued the way it was going without converting then it would have been SVT (camel hump) but it didn't & you can only count what it is actually doing, not what it might have done. When a rhythm starts off as one thing, has a pause, then starts back as a different rhythm then it is a sinus arrest.
Good book: EKG Plain And Simple 2nd Ed. by Karen M. Ellis

Whether it's sustained or not, any fast rhythm that originates above the ventricles is SVT. SVT is a catch all term that includes sinus tach, rapid A-fib, rapid A-flutter, re-entry SVT, and rapid junctional rhythms, although we often incorrectly use it to refer to a re-entry SVT. SVT that self-converts to NSR is still SVT.

DebblesRN, ASN, BSN, RN · Jun 28, 2013

I agree with many other posters here, strip #1 looks like SR with either PACs or PJCs. Since the rate is about 80, I would lean more towards PACs, but I agree maybe with a 12 lead or switching lead placement, you will be able to tell better whether they are PJCs or PACs.

Strip #2 looks like SVT with a sinus arrest, then conversion to NSR. I have seen a sinus arrest this short with adenosine before, but on average, the arrest will last about 3 seconds. Scariest three seconds of your life when you watch it happen, too. LOL

MendedHeart · Jun 28, 2013

I agree with many other posters here strip #1 looks like SR with either PACs or PJCs. Since the rate is about 80, I would lean more towards PACs, but I agree maybe with a 12 lead or switching lead placement, you will be able to tell better whether they are PJCs or pacs .. LOL[/quote']
It can be sinus rhythym because the r to r on the underlying rhythym is irregular. Its def a sinus arrythmia.