Name that ECG: 88 year old male

Today our goal is to interpret the ECG to its fullest from a "cold read" perspective. We're giving you the patient's age, chief complaint, and ECG…and that's it!

88 year old male, weakness.

Name that ECG: 88 year old male

Rhythm:

  • Rate?
  • Regularity?
  • P-waves?
  • PR interval? Associated?
  • QRS width?

Bonus points:

  • Axis?
  • QTc?
  • Bundle branches?
  • ST/T-wave changes?

What are your differentials?

Posts which include any permutation of the phrase "treat the patient not the monitor" will be deleted and their author will be reassigned to the unit that never gets off shift on time, you have been warned.

11 Comments

  • akroeze says:

    I'll answer this in the exact format you have provided.  Correct me where I've made any errors please, only way to learn!

    Rhythm:

        Rate? Atrial is about 125, Ventricular is about 30 (rough)
        Regularity? Very regular
        P-waves? Yes although probably a non-sinus origin
        PR interval? Associated?  Not associated
        QRS width? Narrow, seems to be about 100ms (hard to see for sure)

    Bonus points:

        Axis? QRS axis shows a left axis deviation at about -50
        QTc? 290ms (not sure on this one… just went with an online calculator)
        ST/T-wave changes?  Downward sloping ST depression with T-wave inversion in I, aVL.  T-wave inversion V3-5 and maybe in V2 as well.

    Interpretation: 3rd degree AVB with an underlying Ectopic Atrial Tachycardia and a Junctional Escape.  Probably some form of ischemia but no overt STEMI noted.
     

  • akroeze,

    For the QTi/QTc it would be sufficient to measure against 1/2 the R-R interval. That being said, using Bazett's Formula (QTc = QTi / √RR), you have a ventricular rate of 30 which is an R-R of 2000 ms and a QTi of 480 ms perhaps (V3). 480 / √2000 is ~340 ms.

  • I agree with nearly all of what Akroeze said.  It's impossible to visualize any atrial activity in the 6 limb leads and half of the precordial leads.  Here, atrial activity is only observed in leads V1-3 with V2 being the best to see P-waves in.  Without the benefit atrial activity in the limb leads, I don't think it's possible to say for certain what form of A-V block this is.  You can't establish precise relationships between the P-waves and the QRS complexes.  Despite not being able to see P-waves in the limb leads, I do believe that they are present anyway.  The voltage of the P-waves is so low that they are isoelectric.  The P-waves are also diphasic (+/-) in V1-3 and might be of sinus origin but I don't think you can rule out atrial tachycardia.  My two differentials would be either (1.)  Sinus (? atrial) tachycardia with complete A-V block and resulting idiojunctional escape rhythm or (2.)  sinus (? atrial) tachycardia with 4:1 high-grade (advanced) A-V block.  I would not hesitate to acquire and record either a S5 lead or a Lewis lead in order to enhance the atrial activity and make it more prominent.  Irregardless of the form of A-V block, this patient probably needs a permanent pacemaker implanted.  It would be interesting to know if this patient is on digitalis or not. 

  • GK says:

    I would have to go down the road of maybe a Junctional rhythm on this, the rate is consistent with junctional rhythms and when looking at the 6 second lead II strip on the bottom I do not see ANY P waves indicative of SA or AV node activity. If they are hiding within the line then okay its one hell of a heart block, but otherwise I think this depicts an almost lethal junctional rhythm. I’m just not sure there is going to be much cardiac activity with such little energy depicted by the EKG. #my2cents

  • GK,

    What do you make of the regular blips in V1 through V3?

  • Jesse says:

    Regular rhythm at a ventricilar rate of 30 atrial rate of 125, p waves noted in leads v1-v3, pr interval cannot be determined as the p waves are not associated with the qrs complex, pathologic L axis deviation, LAFB, no bundle branch blocks noted, T wave inversion possible ischemia. Bradycardia with 3rd degree AV block and LAFB

  • Ken Grauer says:

    BELOW WHAT I JUST POSTED ON THE FACEBOOK PAGE:

    Good challenge tracing. Lots of excellent answers proposed. I'll give my "take" to provide an additional perspective.

    First as to which lead is better – lead V1 vs lead II ? – My answer being that BOTH leads are good (and usually the best to tell what is going on). Lead V1 anatomically lies just below the right atrium – so it is "close" and often gives an excellent P wave. The decided advantage of lead II is that IF lead II is upright – then you KNOW you have a sinus rhythm – whereas the "normal P" in lead V1 may be either upright, negative, or biphasic (positive then negative) – so you cannot as definitively tell IF you truly have sinus rhythm simply from looking at lead V1. I always look at both. Particularly for rhythms such as AFlutter – or to find that retrograde P wave in AVNRT, lead V1 is often excellent.

    As to this rhythm – to me the correct answer (my opinion) is that I can NOT tell for sure what the "degree" of AV block truly is. It's not just junctional or ventricular escape – because as described by many there ARE clear P waves present (best seen in lead V2, but also in V1) – but those are the ONLY leads in which I see P waves in …..  So – I'd like to see MORE before I definitively say there are P waves and that there is a regular underlying sinus rhythm …. (more rhythm strips at least – and probably an MCL-1 would should nice P waves since that provides a similar viewpoint to lead V1).

    The other important reason why I believe (as per Marriott) that you can NOT tell for certain that this is 3rd degree AV block – is that the ventricular escape rhythm in the lead II rhythm strip below is NOT completely regular. This may be due to: i) slight variability in the ventricular escape rhythm (which may occur) – or to me, more likely due to SOME conduction which causes the 3rd beat to occur slightly earlier …. – but since I can only see P waves in V1,V2 – I cannot tell if this is what is happening.  

    As to the site of the escape rhythm – I'm not quite sure. The QRS looks like it may be a tad wider-than-it-should-be – but hard to be sure if it truly even makes 0.10 second …. So I don't know if this is: i) ventricular escape; ii) junctional escape; iii) His escape; or iv) escape from some other part of the conduction system, be this the fascicles or elsewhere. Without knowing if this is a junctional rhythm or not – it is difficult to make any assessment re QRST morphology ….

    Bottom Line – This is a symptomatic 88yo man with weakness and a very slow rate. We NEED to first rule out potentially "fixable" causes of bradycardia (= acute ischemia/recent infarction/rate-slowing drugs/hypothyroidism). If none of those are operative – then the patient has Sick Sinus Syndrome. He manifests marked bradycardia, be this due to 3rd degree AV block vs high-grade 2nd degree AV block vs some type of escape rhythm. If he has nothing "fixable" – then he needs a pacer ….

    P.S. Usually I can see SOME semblance of a P wave in lead II – so I am not yet convinced that what we are seeing in leads V1,V2 is "real". It may be – and MCL-1 monitoring plus comparison with prior tracings should tell the tale – but I don't think it definite that "true" P waves are present without more info …

  • Floyd says:

    I am going to post something different than the previous, so i may be wrong but its worth a shot right? Could it be a RBB and a LAFB? The morphology of v1-v2 also seems concerning w/ possible elevation. To bad only a few p waves are detectable, maybe a good case for the lewis lead? But with the visible p waves in v4,5,6 it appears that it may not be dissociated. Also christopher, I learned if the qti is more than 1/2 the r-r interval it is prolonged but is there a quicker more accurate formula than the one you stated above? I may have totally missed the mark here but just trying to think outside of the box.

  • Christopher says:

    Floyd,
    Good eye on the elevation, I too would be concerned about that.
    As for a quicker formula for the QTi/QTC, it unfortunately isn't any better when using other formulas (Fridericia's comes to mind). The 1/2 R-R is a good gut check, but keep in mind a number of normal ECG’s will appear to have a prolonged QT using this approach.

  • Robert says:

    Interpretation: Presence of P waves, Slow, Regular, Narrow = High Degree Heart Block

    Sinus Brady w/ either Mobitz II or 3rd Degree, LAD (Negative Deflection in II,III, avf), Incomplete RBBB (qr pattern in v1/v2, slurred S wave in v6, >100ms), ST elevation in V1-V3, Ischemic patterns/Twave inversion in v4,v5,I, and avl. 
    St elevation in v1-v3 w/ the specific rbbb morphology is abnormal, if anything there should be mild st depression, it is in fact normal for there to be ST depression in v1-v3 on any RBBB. In addition, the ischemic patterns in v4,v5, I, and avl  w/out presence of repolarization abnormalities suggest acute ischemia. Then combine the block and i'd be wanting to send this guy up for pacemaker and some stents…
    I don't think the ECG meets full criteria for IRBBB or LAFB, but it's close. The criteria that i've been taught for IRBBB is >100ms, slurred s waves in V6 & I, and qR/rsr' pattern in v1/v2. For the LAFB i'm not seeing distinct qR pattern in I/AVL and for the IRBBB i'm not seeing s wave in I.
    As for the presence of P waves, if P waves are noted in any leads, specifically V1,V2 then it should be considered real until proven otherwise. There is distinct P Wave morphology w/out evidence of any artifact. You'd be suprised on how often you can ONLY find p waves in those two leads. Lewis lead would be great here.
    .
     

  • Mike McD says:

    I agree with most everything mentioned above, but I will add slow 5:1 atrial flutter to the ddx.  I also see the slight STE in V1-V2, q waves forming, T wave inversions, and poor R-wave progression. Very concerning.  There could be actual P-waves when I look at V4-V6 (like everyone else, I'm not sure what is going on with atrial activity).   Some of the T waves remind me of Wellen's syndrome.  Whatever is going on, I would want a cardiologist to look at this person.  I'm looking forward to the conclusion–Thanks for the interesting case!

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