EKG of the Week

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+ EKG Interpretation

Dr. Ohlbaum's Explanation

Interesting rhythm isn't it?

When a rhythm is hard and changing as this one is, the easiest place to look is the rhythm strip leads at the bottom. The leads do not change so you get a longer look and they are chosen (especially II and Vl) because P waves usually prominent in those leads. So, let's start with that.

The first 4 beats are sinus, normal looking P waves (upright in inferior leads), followed by a narrow QRS. Then, it all gets hard.

After that first 4 beats there are 2 beats that are early, and wide but they are preceded by P waves so I think they are aberrantly conducted PAC. The rest of the tracing has a rhythm that is faster than the sinus in those first beats. Those P waves are very different from the sinus P waves and in fact upside down in the inferior leads. That means they cannot be sinus beats, they are ectopic beats coming from the lower part of the atria (not the sinus node). And during that part of the EKG there 3 other beats that are early, wide and not preceded by a P wave so are PVC's.

So, the initial 4 beats are sinus rhythm, then 2 aberrantly conducted PAC, and a long run of ectopic atrial tachycardia (rate in that section about 130) with frequent PVCs.

What about the rest of the reading:

He has a leftward axis. In the inferior leads, there are Q waves in II and maybe AVF (you do not get too long to look because of those wider ones) which raises the question of an old (or at least not new) inferior Ml. Looking at the precordial leads, there are Q waves in Vl (that would be normal) and V2 and V3 (not normal) suggesting an old (or again, likely not new) anteroseptal Ml. Lastly, look at the progression of QRS and Tin V4,5,6 - it does not make sense the way it is recorded, I think VS and V6 have been reversed (as if the tracing not challenging enough!)

Further Reading:

  • None

Follow up EKGs:

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