EKG of the Week 2019 9-8

This EKG comes courtesy of Dr. Litvak.

 

An 83 year old female with a history of COPD and CAD presents to the ED with a brief episode of right sided chest pain associated with palpitations. Patient denies syncope. No nausea or vomiting. No SOB.

Vital signs: Pulse – 80, R – 18, BP - 144/92, O2 sat 98%.

Her EKG is attached.

2019 9-8.jpg

1.     What is the rhythm?

2.     How would you manage this patient?

ANSWER:

Sinus rhythm with non-conducted PAC’s

 Non-conducted PAC’s are treated the same as patients with PAC’s – look for a cause, check electrolytes, usually no emergent intervention needed.

 

The EKG demonstrates a sinus rhythm at a rate of approximately 80. After beats #4, 7 and 11, there are P waves with no QRS complex following them.

2019 9-8b.jpg

However this is NOT 2nd degree AV block. If you map out the P waves, the “dropped” P waves come earlier than expected. In fact, they come right after the preceding T wave. Since the P waves come so early, the ventricles are still refractory so they do not conduct.

The way we know this is not AV block is because the P waves come earlier than expected. This patient needs no emergent intervention and should not have a pacemaker placed.

Non-conducted PAC’s may appear like a 2nd degree AV block. You see P waves with no QRS complex following them and a pause on the rhythm strip. However, to call something 2nd degree AV block, the P waves must come on time (i.e. the P-P interval must be regular). So, whenever you diagnose AV block, measure the P-P intervals and make sure they are regular. If the “dropped” P wave comes early, it is likely a non-conducted PAC and not AV block.

Non-conducted PAC’s are a very common cause of pauses on EKG. Whenever you encounter a pause, look back at the preceding T wave before the pause to see if there is a P wave buried in there.

Pauses on EKG can be caused by 3 things: Non-conducted PAC’s, SA node disease (SA block and SA arrest), and AV block. The following algorithm may be useful to diagnose pauses:

Algorithm Pauses.jpg

EKG of the Week 2018 3-18

This EKG comes courtesy of Dr. Litvak.

 

An 83 year old female with a history of COPD and CAD presents to the ED with a brief episode of right sided CP associated with palpitations. Patient denies syncope. No nausea, vomiting. No SOB.

Vital signs: Pulse – 80, R – 18, BP - 144/92, O2 sat 98%.

Her EKG is below.

2018 3-18.jpg

1.    What is the rhythm?

2.    How would you manage this patient?

 

ANSWER:

The rhtyhm is sinus rhythm with non-conducted PAC’s

Non-conducted PAC’s are treated the same as patients with PAC’s – look for a cause, check electrolytes, usually no emergent intervention needed.

 

The EKG demonstrates a sinus rhythm at a rate of approximately 80. After beats #4, 7 and 11, there are P waves with no QRS complex following them (See below). However this is NOT 2nd degree AV block.

2018 3-18b.jpg

 

If you map out the P waves, the “dropped” P waves come earlier than expected. In fact, they come right after the preceding T wave. Since the P waves come so early, the ventricles are still refractory so they do not conduct.

The way we know this is not AV block is because the P waves come earlier than expected. This patient needs no emergent intervention and should not have a pacemaker placed.

Non-conducted PAC’s may appear like a 2o AV block. You see P waves with no QRS complex following them and a pause on the rhythm strip. However, to call something 2o AV block, the P waves must come on time (i.e. the P-P interval must be regular). So, whenever you diagnose AV block, measure the P-P intervals and make sure they are regular. If the “dropped” P wave comes early, it is likely a non-conducted PAC and not AV block.

Non-conducted PAC’s are a very common cause of pauses on EKG. Whenever you encounter a pause, look back at the preceding T wave before the pause to see if there is a P wave buried in there.

Pauses on EKG can be caused by 3 things: Non-conducted PAC’s, SA node disease (SA block and SA arrest), and AV block. The following algorithm may be useful to diagnose pauses:

Algorithm Pauses.jpg

EKG of the Week 2017 9-10

A 52 y/o male with a history of HTN presents to the ED complaining of palpitations on and off x 2 days. He reports he has been drinking a lot of caffeinated beverages. He now feels palpitations which begin abruptly, last 1-2 hours, then resolve. They have been recurring over the last couple of days.  His EKG is below.

2017 9-10.JPG

1.    What is the rhythm?

2.    How would you manage this patient?

 

ANSWER:

The rhythm is sinus rhythm with non-conducted PAC’s

Non-conducted PAC’s are benign and usually require no treatment. The main point is to recognize this is NOT 2nd degree AV block and the patient does not need a pacemaker.

 

The EKG demonstrates P waves followed by QRS complexes. However, the rhythm is not completely regular. Beats 3 and 10 come early. These are premature atrial contractions (AKA PAC’s). We also see pauses on the EKG (after beats 5 and 7). At the beginning of those pauses, we see P waves buried in the preceding T waves. (Look at the notching in those T waves and compare them to the other T waves in the rhythm strip.) These P waves come earlier than expected and therefore also represent PAC’s. However, note that there is no QRS complex following these P waves. This happens because the P wave comes so early, at a time when the ventricles are still refractory. So, they do not conduct. These are called non-conducted PAC’s.

Non-conducted PAC’s may appear like a 2o AV block. You see P waves with no QRS complex following them and a pause on the rhythm strip. This is usually typical of 2nd degree AV block. However, to call something 2nd degree AV block, the P waves must come on time (i.e. the P-P interval must be regular). On our EKG, the P waves come early (i.e. the P-P interval is irregular). So, the reason the ventricles do not conduct is NOT because there is a block in the AV node. It is because the P wave came too early and the ventricles are not ready to contract yet. So, this patient does not have AV node disease and does not need a pacemaker.

Non-conducted PAC’s are a very common cause of pauses on EKG. Whenever you encounter a pause, look back at the preceding T wave before the pause to see if there is a P wave buried in there.

Pauses on EKG can be caused by 3 things: Non-conducted PAC’s, SA node disease (SA block and SA arrest), and AV block. The following algorithm may be useful to diagnose pauses:

Algorithm Pauses.jpg