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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Comments
Anthony Garlick
68 y.o. male with weakness: “Treat the monitor, not the patient?”
So my working clinical impression would be hypoglycaemia with possibly dehydration and an electrolyte imbalance. Reasoning for this is that the patient frusemide and metolazone are both diuretics are known to cause these problems. ECG does have a wide and bazar QRS complex with ? ? AV disassociation plus what looks to be peaked T…
2014-09-30 22:22:35
jason
68 y.o. male with weakness: “Treat the monitor, not the patient?”
I'm with Dave Eastman on this. I think it's hyper K+ and will treat as such. But I'll do that will I head to the PCI capable facility. Do I think there is an underlying STEMI? Nope, I sure don't. Do I know the computer has a hard time with false positives? yup. Am I…
2014-09-28 22:15:54
Rodrigo Furtado
68 y.o. male with weakness: “Treat the monitor, not the patient?”
I did forget, is it possible pacer is placed??? sorry that went right over my head.
2014-09-28 20:38:19
Rodrigo Furtado
68 y.o. male with weakness: “Treat the monitor, not the patient?”
1) Change to every lead? STEMI is questionable on my Dx # 6 on a list of 5. IF my recall on this, IF a Global presentation of ST change with QRS Change: a) STEMI is extremely unlikely or NOT STEMI b) start looking for mechanical problems ( tamponade) or chemical/ electrical (electrolyte imbalance or…
2014-09-28 20:34:36
Dave Eastman
68 y.o. male with weakness: “Treat the monitor, not the patient?”
My first thought was hyperkalemia. If the pt is stable, begin with Ca++ & bicarb. Consider albuterol. Serial 12-leads. Start toward PCI capable facility. If it is hyperkalemia, initial treatment should begin to improve pt's condition and there is no harm caused from the increased transport time. If there is an underlying MI as well,…
2014-09-28 18:05:12

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