This is Part 1 of the conclusion to 15 year old male CC: fall from vehicle.
Lots of great comments, including an unexpected sidebar discussion on appropriate C-spine clearance! All of our cases on EMS 12-Lead have been altered from their original form to protect patient and provider privacy and it appears I changed things enough to give a different focus. So let's quickly touch on the consideration of spinal immobilization in this case.
Given an alert and oriented patient, normal neurological exam, negative pain to the C-/T-/L-spine, no distracting injuries, and no intoxication, it is not unreasonable to forgo immobilization in this patient. When our story contradicts our patient presentation, we should find the middle ground. Given our physical findings consistent with a more moderate mechanism an unstable spinal injury is unlikely. Yet, given provider suspicion it is also not unreasonable to place this patient into spinal immobilization. I think you can sell it either way.
However, the patient presentation in this instance was meant to be a distraction for our readers! Let's revisit the first strip to see why:
We've only got one lead, and as some commentors noted there is a lot of artifact. However, lead II has some clear parts with interesting findings that one of the crew members marked up!
We can see regular atrial activity and regular ventricular activity, yet it seems off. Many readers pointed out the likely cause is a 1st Degree AVB with artifact. Based on this strip alone that is the most reasonable explanation. However, as everyone pointed out, it would be prudent to get a cleaner strip and a 12-Lead to confirm our suspicion.
At first glance, our next strip points to uncomplicated 1st Degree AVB. However, as one of my instructors often pointed out, "the PR-interval will not progressively shorten." A closer look at the second strip shows a progressively shortening PRi which eventually prolongates again!
This cannot be an uncomplicated 1st Degree AVB.
By our third strip it is obvious we have something more than a simple prolonged PRi. Leads II and III show hidden P-waves marching out from underneath the QRS complexes. We now have more P-waves than QRS complexes, leaving us with at least a 2nd Degree AVB or a 3rd Degree AVB.
The next two strips were sent in but not included in the original discussion, however, I hope they foster additional discussion as to which high-degree AV block is present.
In the above strip, compare leads II and III closely. Contrast that with your findings in the below strip:
- Given our findings does the argument for a 1st Degree AVB still stand?
- Is a 2nd Degree AVB or 3rd Degree AVB present? Could both be present?
- If it is a 3rd Degree AVB is it complete or is there occasional capture?
- Is it reasonable that our patient's traumatic injury is the cause of these isolated findings on the ECG?