15 year old male CC: fall from vehicle

It has been a busy afternoon as the local schools are out for the Thanksgiving holiday. You've shift traded to get a longer vacation and are working with a newer paramedic. It's not long after dinner when you're paged out for a motor vehicle collision with an ejection.

The details are hazy, but first responders on scene report a young man was thrown from the bed of a small pickup truck.

As you arrive, you notice the pickup truck involved appears undamaged and a crowd has gathered along the curb. You're met in the road by the officer from the engine company who tells you, "the kid was lucky, seems fine; thrown from the bed after they hit a pothole."

The facts appear to be that the pickup was traveling around 45 mph when it struck a pothole throwing the patient–who was sitting in the bed on the wheel well–out onto the street, remarkably landing on his backside without incident.

Your partner passes you and begins his patient assessment. 

  • Conscious, alert and oriented to person, place, time, and event
  • Answers all questions appropriately and without hesitation
  • Denies neck or back pain, no pain to palpation of C-/T-/L-spine
  • Pain to palpation of left knee, thigh and hip without deformities, crepitus, shortening, or rotation
  • Good pulse, motor, and sensory function in all four extremeties
  • Denies alcohol or drug use

He concludes spinal immobilization is not necessary and directs a first responder to let go of manual inline stabilization.

The patient's father has arrived on scene and asks that he be taken to the local hospital for further evaluation. The engine company helps lift the patient to your stretcher and secure him for transport.

Your partner says, "I've got this," and you begin routine transport to the local ED. Vitals are obtained in the back of the unit.

  • HR: 60, regular
  • BP: 118/72
  • RR: 18, unlabored
  • SaO2: 100% on r/a

A further interview reveals no past medical history, no medication usage, NKDA, and only seasonal allergies.

Given the routine nature of the transport, you're a bit suprised to see your partner's head appear in the pass-through holding a 3-Lead, "does this look funny to you?"

At the next stop light, you take a quick look at the strip and ask to see another. He hands you a second strip.

A pile of strips is forming on the bench seat while the car behind you honks impatiently, he continues, "here is the weirdest looking one!"

His next question is short, "should we divert?"

Update 18 July 2011 17:24 EST

As you arrive at the ED your partner hands you the following 12-Lead.

  • What do these rhythm strips show?
  • What does the 12-Lead show?
  • Is there cause for concern?
  • Does this patient require immediate treatment?
  • Do you divert from the local ED to a larger hospital with specialists?

43 Comments

  • Troy says:

    Id call that a second degree type II conduction with a Delta wave. Continue monitoring and procainamide if he goes into a SVT

  • mcg says:

    It's likely a congenital complete AV block (the rhythm strips aren't long enough to observe the dissociation, but the variable AV relation between them is the hint) – if the pt's stable (vitals and conscience are fine), no need for concern nor to divert the ambulance. A cardiology consult (even ambulatory) to plan an adequate follow-up.

  • Troy says:

    Hopefully the delta wave recognition let’s you know I believe WPW is part of the rhythm

  • VinceD says:

    Very tricky one there Christopher, I'm looking forward to seeing the ladder diagrams I'm sure you made…
    My interpretation:
    1) Sinus Tachycardia at ~120 bpm, ventricular rate of ~60.
    … and that's all that I'm certain of.

    My first thought was 2:1 AV-block, but there is a great variation in the PRi between the strips, so then my mind had to head toward AV-dissociation with a junctional escape. The problem with that second option is that there are plenty of p-waves that 'should' be conducting but are not clearly doing so, leaving the kid in a 3rd degree block with junctional escape; such a zebra I'm not going to accept it at this point. So back to 2:1 AV block with a variable PRi, which pretty much leaves my final option of Type I AV block (Wenkebach) with 2:1 conduction. It would be nice if there was a section of strip not in 2:1 block so that I could confirm that the atria and ventricles do in-fact communicate, but at this point I'm pretty comfortable settling on that interpretation.

  • Jaguar says:

    Based of the ECG, probably he's having 3rd Degree HB. The patient as of present is stable and doesn't shows any signs and symptoms of cardiac compromise. Eventhough, that at present he's stable, this ECG finding , cause a concern for me, because this is a high degree HB and patient could crash anytime.. My treatment is to support C-A-B, O2, 12 Lead ECG, IV Line, Cardiac and Sp02 monitoring, get prepared my Atropine and TCP, and expedite transport to appropriate facility for expert cosultation (larger ED/Hospital).

  • Jim Bianga says:

    I am going to guess he has a total AV block with a junctional escape. the 3rd strip shows the P wave before the QRS and at the end the P wave is after the QRS. P waves are marching out different then the QRS. QRS is not ventricular, not wide enough. Junctional?!

  • Ethan Vizitei says:

    seems too me that the pattern is too regular to be total AV disassociation, especially when looking at strip 2.   If I accept that as a premise, there's definately a delay in conduction.  I can't go with WPW specifically because of that delay, the conduction pathway should result in a very short PR interval, not this super long one. What's most interesting are the R' waves that kind of look like the r-S-R' pattern common for RBBB.  I'd be interested in doing a 12-lead, ST-elevation in leads V1-V3 could indicate Brugada syndrome. 

  • saim says:

    can someone explain to me why that would not be a first degree block? seems to me like there is a t wave, followed by a p wave, and a larger than normal pr interval, but there is still 1:1 p:qrs ratio, am i missing something?

  • shuffleking says:

    textbook/ classic case for example of treating Patient NOT the monitor, strip #1 was only picture i could enlarge & look @- the strip clearly shows two (2) leads aren't attached?? anyway  re-evaluate the vitals, repeat OPQRST., medical history, etc. recheck leads & how much is 'roadtrash' vibrating patient around ??   

  • HawkeyeEMTP says:

    I agree with saim.  My interpretation is that it is a 1st degree AV block.  I think it's pretty clear in the second rhythm strip.  There's a P wave for every Q, the only difference is that the PR interval is over 0.20 seconds.  I also see delta waves, probably indicating WPW.  A 12 lead would produce a better interpretation of that though.  But, I see no need for a 12 lead unless I had some other information leading me to believe that he would be go into a PSVT.  A 3rd degree block would require AV node dissociation from the atrial impulses, but nothing in the strip seems to be showing that.  I know many medics make the mistake of interpreting a 3rd degree as a 2nd degree, but I only see a 1st degree (lengthened PR interval).  The bump right before the T wave that I can see best in the first rhythm strip would appear to be a U-wave.  Continue transport to closest ER and monitor.

  • Jim Bianga says:

    I agree with you shuffleking!!!! Always treat your pt!!! The vitals showed he was stable, monitor, take to the ER and treat.

  • Brandon O says:

    I vote complete block with junctional escape. Vince, I must have a higher threshold for incredulity than you :P
     
    Arguments:
    1. Could it be Wenkebach? Yes, but we have both an irregular PRi and intermittent conduction, so you're proposing, at a minimum, a 2:1 block with Wenkebach elongation. Anything's possible but this is a little Procrustean.
     
    2. I'm not convinced the PRi is steadily lengthening, anyway. Someone with calipers can check but it looks like it's just generally increasing *and* decreasing, which is far more consistent with dissociation.
     
    3. Are we really prepared to accept a PRi of well over .400 in some complexes, and still say that there's association?
     
    I am convinced there's a complete block. The atrial rate is just very close to twice the ventricular rate, so they tend to blend together very well. A strip of, oh, six feet or so in length would help.
     
    It looks sinus but I could be convinced of an ectopic atrial origin. Someone with calipers should march out these Ps to look for exact regularity or no. The ventricular rate too. I would guess congenital; connecting this to the injury seems like a stretch. Keep an eye on him but it'll probably be sorted out by cardiology non-emergently.
     
    Troy, I see the delta waves if I squint, but no matter how I squint I can't think of any way there could be an accessory pathway that conducts with a *long* PR interval.
     
    saim: there's some more P waves in there if you look! The PR interval is also quite irregular.

  • Dessie says:

    I was too going with a 1st degree HB, especially by the last strip and also that the kid probably has some underlying condition either unknown to him or just not mentioned in the above scenario. I'm not even too sure about the accuracy of the initial strip. I have gotten a lot of funky looking strips on inital hookup, if the ambulance is bouncing down the road, or any other little factors that can cause a rhythm to look unusual. Does the manual pulse match the rate of the monitor? Treat the patient, not the monitor has been drilled into my head from day one. All the kid's vitals are good and as long as they stay that way and he has no further rhythm changes, continue routine transport, no need for diversion. And just a side note, I probably would have still fully immobilized him, simply due to the speed and mechanism of injury. :)

  • Andrew Moose says:

    I too am going with a 1st Degree HB.  And I agree with Dessie I would have kept him fully immobilized bc of his MOI.

  • Troy says:

    And FYI, according to Garcia and Holtz, not all WPW patients have a short PRI. The “shortening” from the delta wave (Kent bundle depolarization) overlapping on the normal conduction. If the PRi is prolonged then it wouldn’t shorten it more than the delta wave conduction could

  • OldSchoolMedic says:

    It's a 3rd degree block.  The P waves are regular and so is the QRS.  Remember, just cause you can't see the P waves doesn't mean they aren't there.  They are hidden in the QRS.  Also, that's not a delta wave.  It's the P wave not entirely covered up by the QRS. 
    1. take a junctional interpretation out of the mix.  There are P waves and they are upright.
    2. take WPW out of the equation.  It's not a delta wave and the rate isn't tachy.
    3. forget the other HB.  There are too many P waves to be either a 1st or 2nd degree block.
     
    Rhythm interpretation aside…treat based on Pt presentation.  This goes for all Pt's regardless if they are 15 or 50.  Remember people, just cause you CAN treat something, doesn't mean you SHOULD treat something.

  • Corey Younger says:

    Clearly AV disociation is present.  The atrial rate just happens to be almost exactly twice the ventricular rate so it is subtle.  No Delta waves present- upslope R wave distortion from buriied P-wave.  The ventricular focus is most likely  from the Nodal-His junction given QRS width and rate.   No reason to believe this is an acute change given HPI.  Non-emergent transport to a receiving facility that has Pediatric Cardiology for consultation is possible.

  • Aaron says:

    AV block. prob cardiac contusion, possible PE., or congenital. Transport report your findings moniotr for any rapid change of the pt. I lean toward congenital. DO I possibly see bundle branch also?

  • Nick Adams says:

    Sinus in origin with a sinus nodal rate of an average of 600 ms, or 100 bpm with mild sinus arrhythmia which can be normal secondary to respirations.
    R-R:  Regular with a ventricular rate of approximately 50 bpm.  Hmmmmmmm………2:1
    PRI:  Starting @ 420 ms which decreases to 310 with the last complex.  It does howver stabilize @ 320 ms for a couple of beats towards the end.
    Interpretation:  Could be a 2nd degree type I, with the PRI decreasing across the strip.  It also could be a Type II.  My best guess would have to be a CHB with a juctional escape, or 3rd degree AVB (type I).  The 12 lead shows AV dissociation, 2:1 type conduction, but the atrial and ventricular rates are so close to 100 bpm and 50 bpm respectively, that this may be the reason for the illusion of a 2nd degree AVB (type II).  Correct me if I'm wrong, but as far as the WPW delta wave, I don't think that this showing ONLY in lead II to be diagnostic.  We in NH, do not place a pt in full spinal precautions based on MOI alone.  We do a complete physical exam an use our C-spine clearence protocols…….100% accurate.  He more than likely had this all his life.  How many kids with no medical history and takes no medications do you know who was ever on a heart monitor, or had a 12 lead ekg?  No need to treat this rhythm or divert.  He will, at some point in time in his future, need a cardiology consult.

  • Terry says:

    Gutsy move not to immobilize onto a LSB. He was ejected at 45 mph. As for the monitor. Ask the patient are you sure you don’t have a cardiac hx. If not you do now. II degree type 2. Wouldn’t call it CHB because of the narrow qrs.

  • Wheels says:

    Very good Arron. Dont over think it. there was little discussion of the underlying cause of this dysrythmia. Acceleration/deceleration of internal organs. Conduction system its trying to “Catch up”. Be prepared, but don’t get caught up in drugs and “What ifs”. Standard ALS precautions, quiet transport, and transport complete at local ED covers all of a paramedics responsibilities and minimizes liability concerns nearly wrapped in the gray of this case. Keep it simple. Monitor for pertinent negatives and associated positives, ongoing assessment, treat acute life threats with basic maneuvers first. Hours discussion and knowledge in the discussion.

  • Brandon O says:

    One good point is to make sure this information gets across to the hospital. They may not perform an ECG themselves given the unrelated complaint, and if they don't, this little tidbit will continue to go undiagnosed. This goes back to our recent discussions of asymptomatic cardiac issues found on screenings…

  • Jim Hendey says:

    very difficult but I believe it is simply a type 1 block. if he is stable I wouldn't give it much thought as he has most likely had it awhile. one comment I would like to make as an "old timer" though. The patient should have been in c-spine precautions period! mechanisim of injury is there and there is NO way to determine for sure that there was no cervical injury. these are injurys that are even frequently missed in the ER ; even after a c-spine x-ray.

  • Justin O says:

    Check out this diagram of pediatric AV-dissociation in a textbook of pediatric cardiology:
    HERE
    Quite similar…   Note how they differentiate AV-dissociation from 3rd degree HB because the atrial rate is slower than the ventricular rate in AV-dissociation, and vice-versa in 3rd degree HB.  Now look at the ECG again and see how our patient's atrial rate is ever so slightly slower than the ventricular.
    In the end, I would not divert:  patient is stable for the time being.  If that changes, a decision could be made at that time.  Any hospital which would take a ped who was thrown from a truck moving at 45 mph would surely take a stable patient with some asymptomatic ECG changes…

  • Wheels says:

    I agree with the c-spine comment….100%. Basic……

  • If you couldn't tell, we're on a pediatric kick here at EMS 12-Lead. But, I guess I should jump in and add that names, circumstances, partners, time, numbers, anything really could have been changed! Let's assume that whatever mechanism was involved, if there was any at all, met clearance criteria under the NEXUS criteria:

    1. No posterior midline cervical-spine tenderness,
    2. No evidence of intoxication,
    3. A normal level of alertness,
    4. No focal neurologic deficit, and
    5. No painful distracting injuries.

    I'm loving all the great comments though, keep it up!

  • HawkeyeEMTP says:

    Nick, you are correct about the delta wave.  It needs to show up in the other leads to be diagnostic.  A few months ago, we found out my girlfriend had WPW after a routine yearly checkup.  I have a nice 12 lead of it somewhere.  Her alabation went well.  Now her EKG looks more 'normal', but you can still see a small delta wave in all leads.  Sometimes these ablations don't work 100%, and the WPW can become prominent again in the future.

    Thanks Justin for the link on AV dissociation.

  • Troy,

    For the delta wave to be present there would need to be fusion of the ventricular depolarization from both the bypass tract and the AV node. In the case of a long PRi, due to say 1AVB, I do not believe you could have a delta wave electrically, as the bypass tract will have no such block.

    Thus the recognition of WPW on the surface ECG requires a delta wave and a short PR-interval.

  • Hawkeye,

    Your point about the waves after the T-wave being U-waves is well taken. Many younger patients will have them on resting ECG's.

    I think in this instance it is safe to say they are not U-waves, as their shape is nearly identical to the P-waves that are present and if you look closely the T-U interval is variable (which I do not believe is possible).

  • Terry,

    The width of the QRS complex is dependent on the location of the primary pacemaker, whether it be endogenous or exogenous, even in the setting of a 3rd degree block.

    If the block is low in the atrioventricular junction then we would expect a wide, ventricular escape rhythm to be present.

    However, if the block is higher in the atrioventricular junction, then in an otherwise normal heart we would expect a narrow, junctional escape rhythm to be present.

  • Justin,

    Thanks for the link on pediatric AV dissociation, very interesting definition!

  • HawkeyeEMTP says:

    Yeah, I took another look at the strips and noticed that.
    What seems weird to me now is that the first strip appears to be AV dissociation.  But, then in the second strip, that looks like a 1st degree AV block.  Then, the third strip looks like it's back to AV dissociation.
    With AV dissociation, the atrial rhythm still has the ability to propagate to the AV node.  A 3rd degree block doesn't allow that to happen.  So, now I'm thinking there was a dissociation, then a 'reassociation', followed by dissociation.  I'm sure it could be congential, but given the trauma involved I would think it would be more due to cardiac contusion.

    I know we don't go this far, but I'd be interested to know what the chest x-ray looked like.
    On a side note…  I wasn't aware, but apparently Lyme disease can cause a 3rd degree heart block.  Considering it's tick season around here, I'll stick that in the back of my mind.

  • Hawkeye,

    Out of the box thinking with Lyme disease, and I like it! Given the physical exam is largely unremarkable, and there is no trauma visible to the chest, it does not hurt to explore other possibilities.

  • HawkeyeEMTP says:

    Oh, I wasn't really thinking anything of the Lyme disease.  Just information to share after I ran across it while looking up more on AV dissociation vs. 3rd degree AV block.
    He may not have had any visible trauma to the chest or back, but that doesn't necessarily mean his heart didn't slam up against his ribs, etc. in the fall.  That would be too hard to tell by a physical exam.

    The heart is a funny, sensitive thing.

  • Brandon O says:

    Troy, to expand on what Christopher said: the delta wave is a fusion of the normal AV conduction (slow) and the accessory pathway conduction (fast). Due to the fast conduction from the accessory tract, the P wave is closely followed by the QRS. If there's accessory conduction, I'd expect to see both of these; if there's not, neither. But how could there be a delta wave without a tight PRi? If the accessory tract is conducting rapidly, then the QRS should come quickly, not at the leisurely .400ms pace that the AV node is clearly conducting!

  • Nick Adams says:

    Terri – Not placing the patient on a long board is based on a complete physical exam and Spinal injury clearance protocols:  Greater then 12 y/o, CA&Ox4, No language barrier or ETOH/drugs, no distracting injuries, no spine pain with palpation, no neuorlogical deficits to include parasthesia and distiguishing sharp/dull sensations, no pain with touching chin to chest, and finally no pain with moving head from side to side.  Did you ever notice the the MD in the ED has the patient off the long board before you clear the hospital.  It's not from going to x-ray, it's from doing a thourough physical exam…….and it's very safe and effective.  The MOI only gives us a index of suspicion that ther is a possible spinal injury.  Secondly, it is very possible to have a 3rd degree AVB with a narrow (normal) QRS.  It is total dissociation of the artia and the ventricles with a junctional ecape.  A wide QRS in a CHB is due to a ventricular escape because the AV junction did not take over….so the venticles did to preserve life.
    Christopher W.  -  Lyme disease is a great thought.  It crossed my mind too, but I dismissed it because Lyme disease also causes many other neurological symptoms that are not so hard to overlook, like dysphagia and gait disturbances, etc.
    I would love to see a longer strip of this rhythm to see if the PRI keeps shortening and walks right into the QRS at some point.  Like I pointed out, the PRI is ever-so-slightly creeping closer to the QRS.  If it keeps this up and walks right into the QRS, it's a CHB….If it doesn't, it's a 2nd degree type II.  One thing that keeps haunting me is the fact that the PRI is not SET at a specific interval.  In a 2nd degree type II the PRI that does conduct should be rock solid.  The same is true with a 2nd degree type I (after the dropped beat).

  • Pete Murrell says:

    Hi guys. All very interesting answers…I was just wondering if we ever get "the Answer" in this blog or if it's all just opinions and we are all left wondering?
    I am leaning towards a 1st degree block due to the regularity and the 1:1 P:QRS. But I am by no means an ECG buff. That's why I'm here. To hopefully learn.
    Hope to see an actual answer soon. Cheers guys.

  • Rose says:

    All the strips are showing a 3rd degree/ complete heart block.  I would be concern since per patient and family there is no previous cardiac history. 
    The mechanism of this accident appears to be significant.  Based on  how the pt landed (on his backside), I would be concern about possible traumatic injury to the heart muscle, a form of tearing or strain of the tissue. I would change my destination to a Level 1 or have a cardiologist available for an ultrasound. 
     

  • ben podsiadlo says:

    Lyme disease, unrelated to mva

  • how dare they honk at the ambulance?

  • arnel says:

    This is atrial tachycardia

  • Nick says:

    I'm gonna say 2nd degree with 3:2 conduction. Watch very closely for p waves especially the ones hidden within the QRS complex.

  • Kevin says:

    I agree with hawkeye,  the first strip appears to be AV dissociation.  in the second strip, it looks like a 1st degree AV block.  With the third strip looks like it's back to AV dissociation. Has anyone taken into consideration the truck itself my have disorted the ECG. It only takes 40 hertz to distort the machine. 

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