Please help me interpret this ECG strip

NickB · Aug 18, 2010

You are right that it is definitely atrial, as there is no discernable p-wave. The QRS interval is equal to or less than .12 so there is no issue with the ventricle. I would expect to see an irregular QRS pattern with A-fib. This could be A-flutter, but that looks more like a clear rapid pattern of atrial firings where the p-wave would be, with a regular QRS pattern. Still though, I would venture to say this is A-flutter. It will be interesting to see what some of the cardiac gurus have to say on here. I believe treatment would be with cardizem?

pepitofeliz · Aug 18, 2010

This rhythm is irregularly irregular making it an atrial fibrillation. Treatment would

depend if it is a first time onset,which would require a cardizem drip. However

if it is a preexisting arrhythmia the patient would be on anticoagulant usually coumadin. Also the cardiologist may or not depending on age, suggest an ablation.

grandmawrinkle · Aug 18, 2010

Right, atrial fib, approx 150 bpm.

I don't see any of the ST depression you are describing.

There are many, many drug and non-drug (interventional, surgical as well) treatments for atrial fib. Cardizem is not even close to the only medication used.

IMO nursing students should have an 8 hour lecture on atrial fib and it's treatment. It's extremely common and you will encounter it across almost all practice settings.

Spacklehead, MSN, NP · Aug 18, 2010

I'm going with rapid A-fib vs. possible SVT. There is slight ST-depression in the inferior leads as you noted with borderline Q-waves in lead III. It is very slightly irregular so most likely Afib. Adenosine might help to slow the rate down to see if it is true A-fib to help determine further appropriate treatment (based on patient's symptoms, of course).

HiHoCherry-O · Aug 18, 2010

Looks like A. Fib to me. I also do not really see any ST-depression. You will encounter A. fib a lot during your career. There are many reasons it starts: post-operative, infection, heart attack, just cause. . .

Adenosine is NOT the drug of choice to slow down atrial fibrillation (studies have shown this to actually irritate the atria even more). Calcium channel blockers, amiodarone, cardioversion and ablation are some of the more common treatments for atrial fibrillation. The treatment is chosen based on many factors such as: is this new? How long has the patient been in a. fib? What is the underlying cause (if it can be determined)? etc.

Some people live in a.fib. Some people go in and out of a.fib. A person looses 20% of his/her overall cardiac output when in a.fib. Many people can tolerate this 20% loss relatively well. Others can not.

Hope this helps.

NickB · Aug 18, 2010

I didn't really think the QRS was irregular, but I guess it could be slightly irregular. I will most certainly bow down to the cardiac gurus on here though.

Edit: You know what, as I look further down lead two I see it be more irregular. You guys were right, definitely A-fib.

HollyHobby · Aug 18, 2010

Adenosine doesn't treat A fib, but if the rate is so fast that you can't tell if you have A fib or something else, adenosine is useful for diagnostic purposes.

This is pretty clearly A fib, though.

HiHoCherry-O · Aug 18, 2010

I didn't really think the QRS was irregular, but I guess it could be slightly irregular. I will most certainly bow down to the cardiac gurus on here though.

Are you thinking the width of the QRS or if they evenly march out? Sometimes it is hard to tell when uncontrolled a.fib is in fact a.fib versus a sinus tach (especially when the rate gets into the 140-150 range). The QRS is typically still narrow considering there is not other etiology present. The QRS segments won't march out. If you look at the last strip at the bottom of the 12-lead it is a continuos recording of Lead II which helps highlight the irregularity of the QRS'.

Sometimes people will mistake a.fib for a.flutter. Once you have seen true a.flutter, you will not forget it. QRS segments in A.flutter are also more likely to march out (but not always).

NickB · Aug 18, 2010

Are you thinking the width of the QRS or if they evenly march out? Sometimes it is hard to tell when uncontrolled a.fib is in fact a.fib versus a sinus tach (especially when the rate gets into the 140-150 range). The QRS is typically still narrow considering there is not other etiology present. The QRS segments won't march out. If you look at the last strip at the bottom of the 12-lead it is a continuos recording of Lead II which helps highlight the irregularity of the QRS'.
Sometimes people will mistake a.fib for a.flutter. Once you have seen true a.flutter, you will not forget it. QRS segments in A.flutter are also more likely to march out (but not always).

No, not the width of the QRS, the spacing between them. I wasn't looking at the full strip for lead 2. Once I saw that, it was clear that it is a-fib. Since it's irregularly irregular, you have to see a large section of strip and I just didn't look.

KaliNurse · Aug 18, 2010

A-fib, for sure....A-flutter is REGULAR, a-fib is IRREGULAR. That's one good way to distinguish between the two....and of course, flutter shows the saw-tooth waves:-)

Spacklehead, MSN, NP · Aug 18, 2010

Adenosine is NOT the drug of choice to slow down atrial fibrillation (studies have shown this to actually irritate the atria even more).

No, but if there is the absolute question of Afib vs. SVT, it can slow the rate down for a few seconds in order to help make the determination as to what the underlying rhythm is, and then appropriate tx can be administered. Our ED docs would do this often if they couldn't make the determination.

I do agree, however, that the lead II tracing at the bottom of the EKG shows it to be Afib more likely than SVT so if truly Afib then no, Adenosine would not be indicated as you have stated.