Name that ECG: 88 year old male – Findings

These are the findings for our Name that ECG case: 88 year old male, weakness.

Name that ECG: 88 year old male

(click for a marked up image)

 

Rhythm:

  • Rate:
    • Atrial rate of ~120 bpm, appreciated in V1-V3
    • Ventricular rate of 33 bpm
  • Regularity: regular atrial and ventricular activity
  • P-waves:
    • Appreciable in V1-V3, unknown if sinus but rate is consistent with sinus tachycardia
    • The P-waves may or may not be associated with the QRS complexes, if they are it is a 4:1 association
  • PRi: if associated, high-normal at 210 ms
  • QRS duration: possibly slightly prolonged at 120-130 ms (V3 and V6 are widest)

Bonus points:

  • Axis: -45 degrees, pathologic left axis deviation (down aVF, up I, down II), LAFB
  • QTc: normal (< 1/2 R-R), 351 ms (Bazett's)
  • Bundle Branches: V1-positive (qR), R in Lead I, RS in V6, IVCD
  • ST/T-waves:
    • T-waves: biphasic T-waves in II/aVF/V6, flipped T's in I/aVL/V3-V5,
    • ST-elevation: possible ST-E in V1-V3
    • ST-depression: possible ST-D in I

Differentials:

  • Sinus tachycardia or atrial tachycardia with:
    1. 4:1 2nd Degree AV Block and IVCD
    2. 3rd Degree AV Block with a junctional escape rhythm (IVCD)
    3. 3rd Degree AV Block with a ventricular escape rhythm

Notes:

  • A longer rhythm strip from V2 would better highlight the degree of AV block present
  • A septal MI may be the cause of our patient's heart block and condition

9 Comments

  • Gary H. says:

    What is an appropriate prehospital treatment?

  • Gary,

    Good question! It all depends on the situation, to be fair. On the short list of treatments to consider: pacing, fluids, dopamine/epinephrine if pacing fail, calcium, et al.

  • Dennis says:

    Pt is 88 and possiblly had this history for years ! I would treat with IV and may try pacing  but most likely R/R not going to change and yes Calciun with orders . transport and monitor Pt .

  • Sean says:

    Is it sad that I got these (generally) correct but I'm not even 2 years into undergrad?

     

  • Sean,

    Sad? Sounds pretty good to me!

  • Mike McD says:

    any chance that the bradyarrythmia is related to hypothermia?
    I didn't see prominent Osborn waves (except maybe V5), but it still seems like a possibility.

  • tedbohne says:

    sinus tachycardia, av dissociation idiojunction escape LPFB  r/o ANTEROSEPTAL MI, AXIS IS PARALLEL TO aVL, QRS configuration and p waves clearly seen inconsistant with hypothermia,  AV dissociation most likely rate related. reciprocal changes in I and aVL.  bradycardia consistant with Idiojuncional rhythm.   Tc, cpk?  any lab work.  no third degree block visualized.  if patient's complaint is weakness, admit r/o MI.  pain in older folks may not be present.  fatigue likely due to heart rate.  start O2, IV ns, Pulse OX, monitor, transport Code 1 and observe for changes.   such as evidence of failure, resp. rate pulse ox, hx, meds, pedal edema, check for both pedal pulses, signs of chronic hypoxia, listen as well as you can to lung bases. 

  • Corde Armstrong says:

    I'm going to say it is sick sinus syndrome causing a junctional bradycardia possibly from a septal infarct.

  • Jason says:

    is HR 49 QRS 98ms p/pr 108ms/150ms QT/QTc  452ms  / 433 ms and i donno if it matters but p/qrs/t axis 52 / 76 / 52 degress .   29 yr old male 190 Lbs  6 foot . althetic build . Only reason i ask is that i have some family mebers with bad tickers . lookin for the truth good or bad . Thanks and good luck with ur schooling hope my ? helps

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EMS 12-Lead

Cardiac Rhythm Analysis, 12-Lead ECG Interpretation, Resuscitation

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Comments
Dominic
Conclusion to 59 Year Old Male: Unwell
Great discussion on a difficult 12lead! I follow these very closely and based on pt presentation and 12lead tracing, this was a difficult or to treat with impending heart failure, hypotension, and trouble breathing. Thanks for the follow up and look forward to next week!
2015-07-06 20:53:35
Billy
Conclusion to 59 Year Old Male: Unwell
Hmmmm, I was fairly close. Sounds like most of the treatment occurred IN Hospital. Love case studies, and that one was good.
2015-07-06 20:28:25
Kori
59 Year Old Male: Unwell
There's the point! There is are no P waves, and the rhythm is irregulary-irregular-atrial fibrillation. If you look, it is rsR phenomen-RBBB, BUT there are huge ST elevations on all leads from V1-V5 (that's why the QRS complexes look so broad). I and aVL is clearly ST elevation suggesting STEMI. In limb leads you can…
2015-07-06 10:12:16
Vince DiGiulio
Conclusion to 59 Year Old Male: Unwell
I'll expand on this in the next post but unfortunately I actually wasn't present for this case so I can't give my direct account of how things happened. That said, from the notes I read and word-of-mouth from those involved (which I suspect painted things in a better light than I would have viewed them),…
2015-07-06 04:09:22
Matt King
Conclusion to 59 Year Old Male: Unwell
Hey Vince thanks for the through follow up with this case. I am curious how his rate was controlled since he was hypotensive and maybe an unknown onset of when his A-Fib stated(thinking anticoagulation first)? As you know the wrong approach could be devastating in this PT with risks of further infarction, stroke, or death…
2015-07-05 14:10:57

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