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
Comments
David Baumrind
All that wiggles isn’t Wellens’
@Gary, by all means, nitpick all you like. I agree with your assessment, and the post has been modified. Thank you for the feedback!
2014-08-30 17:28:16
Gary Huntress
All that wiggles isn’t Wellens’
Not to nitpick but is this really a "slightly leftward axis"? I and AVF are both positive. I put it at about +20 degrees, not leftward.
2014-08-30 11:49:35
Handsome Robb
87 YOM COMPLAINING OF CHEST DISCOMFORT AND DYSPNEA
CHF. 12-lead shows a sinus Tachycardia in the 120s with PACs, besides the anterior leads there's diffuse ST depression, the STE in the anterior leads can be explained by the LBBB, axis is good as well. I wish they posted the EtCO2 waveform so we could see but I'm assuming it's non-obstructive. The elevated EtCO2…
2014-08-30 08:08:22
Christopher Watford
“Bad heartburn” – 82 y.o. female without chest pain.
Brooks, Firstly, thank you for the warm welcome to the club. Secondly, the Glasgow algorithm's only published sens/spec for AMI is 51.6%/97.6% respectively (Tuscon STEMI Database). I've not been able to find any other publications. The GE Marquette 12SL algorithm has been widely studied, but is much older, and ranges in sensitivity from 48% to…
2014-08-29 16:50:14
CB
57 Year Old Male–Chest Discomfort
Given what he was doing (paint fumes on ladder painting) I would first question if the pain is reproducable. Yes his ekg isn't normal but looks like old inferior MI. And he is hypertensive. 02 a must. Def. would give ASA. First would give morphine and see how his cp and bp are. If still…
2014-08-29 11:37:25

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