Loading ...
Sorry, an error occurred while loading the content.

Rare ectopic rhythm

Expand Messages
  • Klaus Skrudland
    Hi all. Just want to present to you a case of what I believe is a quite uncommon ectopic rhythm. The patient is a 55 y/o male with a well known paroxysmal
    Message 1 of 31 , Jul 1, 2009
    View Source
    Hi all. Just want to present to you a case of what I believe is a quite uncommon ectopic rhythm.
     
    The patient is a 55 y/o male with a well known paroxysmal atrial fibrillation. He uses flecainide and metoprolol and was admitted for onset of what he thought was atrial fibrillation.
     
    As you will see from the ecg, the ventricular rate is irregular. Right precordial leads show ectopic, positive P waves. PP intervals are regular with a rate of 230 bpm. When marching them out with a caliper (see the dots I made), they seem to march right through the QRS complexes and don´t seem to get conducted. However, there can´t be AV dissociation, as there is no evidence of an escape pacemaker present (and the ventricular rate is irregular).
     
    As a matter of fact, the P waves does seem to get conducted after all. My colleague Terje (the other Norwegian here in the club) pointed out that the PR interval in fact gets progressively longer. And at this point, I´m struggling to understand the rest of the mechanism. Most likely, this atrial tachycardia with some kind of Wenkebach conduction.
     
    Comments? Thoughts? Ideas? Anyone wanna make a ladderdiagram to explain the mechanism?! ;-)
     
    klaus
  • Klaus Skrudland
    This is an old thread. It has been discussed already. Sorry. ... -- Mvh, Klaus Nilsen Skrudland http://www.lapsklaus.com http://ecgblog.com + 47 99 38 67 55
    Message 31 of 31 , Aug 16, 2009
    View Source
    • 0 Attachment
      This is an old thread. It has been discussed already. Sorry.

      On Sun, Aug 16, 2009 at 1:45 PM, swalehin <drswalehin@...> wrote:
       

      --- In ekg_club@yahoogroups.com, haval surchi <havalandonlyhaval@...> wrote:
      >
      > Where is the attachment??
      >
      >
      >  i wanted to comment on this topic.don't know how.
      any way,if this one reaches u,then my answer will b<PAT WITH VARRIABLE BLOCK/CONDUCTION.
      > HAVAL LUTFALLA
      >
      > --- On Sat, 8/15/09, swalehin <drswalehin@...> wrote:
      >
      >
      > From: swalehin <drswalehin@...>


      > Subject: [ekg_club] Re: Rare ectopic rhythm
      > To: ekg_club@yahoogroups.com
      > Date: Saturday, August 15, 2009, 4:02 AM
      >
      >
      >  
      >
      >
      >
      > --- In ekg_club@yahoogroup s.com, Klaus Skrudland <lapsklaus@ ..> wrote:
      > >
      > > Jesse -
      > > You're probably looking at the right ekg, but as you can see the AV ratio
      > > varies from cycle to cycle. The conduction is not 2:1. There also seems to
      > > be AV dissociation, which is also not the case. There is some kind of 2AVB
      > > here, you are correct about that. My problem is that I cannot figure out
      > > which P waves are conducted and which are not, and what the specific kind of
      > > block/conduction this is.
      > >
      > > Paul - I´ve attached them again to this email
      > >
      > >
      > >
      > >
      > > On Mon, Jul 6, 2009 at 2:29 AM, jesse12848 <jesse12848@ ...> wrote:
      > >
      > > >
      > > >
      > > > --- In ekg_club@yahoogroup s.com <ekg_club%40yahoogr oups.com> , "jesse12848"
      > > > <jesse12848@ > wrote:
      > > > >
      > > > > --- In ekg_club@yahoogroup s.com <ekg_club%40yahoogr oups.com> , Nikiah
      > > > Nudell <medicnick@> wrote:
      > > > > >
      > > > > > Hi Jesse,
      > > > > > I just wanted to clarify something you mentioned. Pwaves may be present
      > > > in
      > > > > > PVCs or PACS. One has to be careful to determine whether the Pwave is
      > > > > > 'associated' with the QRS complex.
      > > > > >
      > > > > > Some rythms can be tricky to differentiate in a 12 lead. If it is
      > > > bigeminy
      > > > > > with a bundle branch block, for example, it can be nearly impossible to
      > > > > > determine from a single 12lead which is the ectopy and which is the
      > > > > > underlying rhythm.
      > > > > >
      > > > > > Cheers,
      > > > > > Nick
      > > > > >
      > > > > > On Sun, Jul 5, 2009 at 11:12, jesse12848 <jesse12848@ > wrote:
      > > > > >
      > > > > > >
      > > > > > >
      > > > > > > --- In ekg_club@yahoogroup s.com <ekg_club%40yahoogr oups.com> <ekg_club%
      > > > 40yahoogroups. com>,
      > > > > > > "thatsuthant" <thatsuthant@ > wrote:
      > > > > > > >
      > > > > > > > Hi every one,
      > > > > > > > How do you differentiate atrial ectopic beats from ventricular
      > > > ectopic
      > > > > > > beats?. Any one can define me please?.
      > > > > > > > Ventricular ectopic beats are clearly seen on ECG . But atrial
      > > > ectopic
      > > > > > > beats, how you all find those?. Please give some of your thoughts.
      > > > > > > >
      > > > > > > > Thanks
      > > > > > > >
      > > > > > > >
      > > > > > > >
      > > > > > > > --- In ekg_club@yahoogroup s.com <ekg_club%40yahoogr oups.com> <ekg_club%
      > > > 40yahoogroups. com>, Klaus
      > > > > > > Skrudland <lapsklaus@> wrote:
      > > > > > > > >
      > > > > > > > > Hi all. Just want to present to you a case of what I believe is a
      > > > quite
      > > > > > > > > uncommon ectopic rhythm.
      > > > > > > > >
      > > > > > > > > The patient is a 55 y/o male with a well known paroxysmal atrial
      > > > > > > > > fibrillation. He uses flecainide and metoprolol and was admitted
      > > > for
      > > > > > > onset
      > > > > > > > > of what he thought was atrial fibrillation.
      > > > > > > > >
      > > > > > > > > As you will see from the ecg, the ventricular rate is irregular.
      > > > Right
      > > > > > > > > precordial leads show ectopic, positive P waves. PP intervals are
      > > > > > > regular
      > > > > > > > > with a rate of 230 bpm. When marching them out with a caliper
      > > > (see the
      > > > > > > dots
      > > > > > > > > I made), they seem to march right through the QRS complexes and
      > > > don´t
      > > > > > > seem
      > > > > > > > > to get conducted. However, there can´t be AV dissociation, as
      > > > there is
      > > > > > > no
      > > > > > > > > evidence of an escape pacemaker present (and the ventricular rate
      > > > is
      > > > > > > > > irregular).
      > > > > > > > >
      > > > > > > > > As a matter of fact, the P waves does seem to get conducted after
      > > > all.
      > > > > > > My
      > > > > > > > > colleague Terje (the other Norwegian here in the club) pointed
      > > > out that
      > > > > > > the
      > > > > > > > > PR interval in fact gets progressively longer. And at this point,
      > > > I´m
      > > > > > > > > struggling to understand the rest of the mechanism. Most likely,
      > > > this
      > > > > > > atrial
      > > > > > > > > tachycardia with some kind of Wenkebach conduction.
      > > > > > > > >
      > > > > > > > > Comments? Thoughts? Ideas? Anyone wanna make a ladderdiagram to
      > > > explain
      > > > > > > the
      > > > > > > > > mechanism?! ;-)
      > > > > > > > >
      > > > > > > > > klaus
      > > > > > > > >
      > > > > > > >
      > > > > > > In the caes of a true atrial ectopic beat, the QRS will be preceded
      > > > by a
      > > > > > > definite, upright P wave. P wave morphology may fulctuate (wandering
      > > > > > > pacemaker, etc.), but if the premature beat is truely atrial in
      > > > origin then
      > > > > > > a P wave will be present. Another way to distinguish PACs from PVCs
      > > > is to
      > > > > > > view them in leads I and III. Also remember that PACs have a QRS
      > > > duration
      > > > > > > time of < 0.12 sec, whereas PVCs almost always have duration times >
      > > > 0.12
      > > > > > > sec.
      > > > > > > If your sure that it's a PVC your looking at, you can determine L or
      > > > R
      > > > > > > origin by viewing it in MCL1/v1. L vent PVCs will be positive in
      > > > deflection
      > > > > > > while R vent PVCs will be aberrant. Hope this helps.
      > > > > > >
      > > > > > >
      > > > > > >
      > > > > >
      > > > > Nick, right on. Thats a great catch. It is important to determine wether
      > > > the P wave is in fact associated with the QRS. Thanks for the correction.
      > > > >
      > > > I'm just a lowly paramedic :-), and I just looked at Klaus attached file of
      > > > the rhythm in question. V1 appears to display a 2nd degree type II AV
      > > > blockade. Am I wrong in my interpretation or am I looking at the wrong
      > > > rhythm? Sorry if I sound a little confused.
      > > >
      > > >
      > > >
      > >
      > >
      > >
      > > --
      > > Mvh,
      > > Klaus Nilsen Skrudland
      > >
      > > http://www.lapsklau s.com
      > > http://ecgblog. com
      > > + 47 99 38 67 55
      > >
      > PAT WITH VARYING CONDUCTION.
      > THIS EXPLAINS IRREGULARITY OF QRS COMPLEXES.
      >




      --
      Mvh,
      Klaus Nilsen Skrudland

      http://www.lapsklaus.com
      http://ecgblog.com
      + 47 99 38 67 55
    Your message has been successfully submitted and would be delivered to recipients shortly.