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#12293 From: Russell Stine <rj.stine@...>
Date: Mon Jul 6, 2009 11:54 pm
Subject: Re: Chest pain job, 3 x arrests and an R on T
rj.stine
Offline Offline
Send Email Send Email
 
Nice septal anterior MI, I had one back in March with similar symptoms and would probably have arrested had we not gotten there in time.

Artery on the left  across the front of the heart, feeds the septal wall and front left of the heart. You will get severe bradycardia, CHF symptoms, AV and bundle branch blocks.
 
=====================================
Russell Stine
Firefighter/Paramedic, E23C
Memphis, TN Division of Fire Services
901-596-6609 (Cell)
901-746-9654 (Home)



From: David Thomas <tazambo@...>
To: ekg_club@yahoogroups.com
Sent: Sunday, July 5, 2009 9:07:58 PM
Subject: [ekg_club] Chest pain job, 3 x arrests and an R on T

Hi Guys,

I had a good job yesterday.

My blog has the story and 3 EKG's for you to peruse.
http://tassieparame dic.blogspot. com/2009/ 07/good-chest- pain-job. html

Extra info, not on my blog post, is the patient was:
actually a Male
60 years old
Had lost 50Kg in last 2 years after gastric banding (down from 165kg)
has ? controlled Afib

The second image shows a nice R on T
http://1.bp. blogspot. com/_AuOignBm- 6A/SlFWKjoz38I/ AAAAAAAAACo/ Etc7D3bgz7w/ s1600-h/Vf_ Arrest_0907_ 1.jpg

Can anyone tell my why an LAD occlusion would involve I & aVL ?
I think I need to brush up on my coronary artery anatomy...

Regards
Dave


Access Yahoo!7 Mail on your mobile. Anytime. Anywhere. Show me how.


#12292 From: Klaus Skrudland <lapsklaus@...>
Date: Mon Jul 6, 2009 6:52 pm
Subject: Re: Re: Rare ectopic rhythm
lapsklaus
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Send Email Send Email
 
My bad...

Here it is:
http://www.lapsklaus.com/ekg/EKG-scans/atrial_ectopic_a.jpg
http://www.lapsklaus.com/ekg/EKG-scans/atrial_ectopic_b.jpg



On Mon, Jul 6, 2009 at 6:50 PM, <wegandy1938@...> wrote:


Klaus,

Got the "not found on this server message.  Can you try again?

Gene



**************
Looking for love this summer? Find it now on AOL Personals. (http://personals.aol.com/?ncid=emlcntuslove00000003)




--
Mvh,
Klaus Nilsen Skrudland

http://www.lapsklaus.com
http://ecgblog.com
+ 47 99 38 67 55

#12291 From: wegandy1938@...
Date: Mon Jul 6, 2009 12:50 pm
Subject: Re: Re: Rare ectopic rhythm
wegandy
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Send Email Send Email
 
Klaus,

Got the "not found on this server message.  Can you try again?

Gene



**************
Looking for love this summer? Find it now on AOL Personals. (http://personals.aol.com/?ncid=emlcntuslove00000003)

#12290 From: Stephen Smith <smith253@...>
Date: Mon Jul 6, 2009 1:37 pm
Subject: Re: Chest pain job, 3 x arrests and an R on T
rpmpaddler
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ST elevation in I and aVL means the LAD is occluded proximal to the first diagonal, which feeds the high lateral wall.

On Sun, Jul 5, 2009 at 9:07 PM, David Thomas <tazambo@...> wrote:


Hi Guys,

I had a good job yesterday.

My blog has the story and 3 EKG's for you to peruse.
http://tassieparamedic.blogspot.com/2009/07/good-chest-pain-job.html

Extra info, not on my blog post, is the patient was:
actually a Male
60 years old
Had lost 50Kg in last 2 years after gastric banding (down from 165kg)
has ? controlled Afib

The second image shows a nice R on T
http://1.bp.blogspot.com/_AuOignBm-6A/SlFWKjoz38I/AAAAAAAAACo/Etc7D3bgz7w/s1600-h/Vf_Arrest_0907_1.jpg

Can anyone tell my why an LAD occlusion would involve I & aVL ?
I think I need to brush up on my coronary artery anatomy...

Regards
Dave


Access Yahoo!7 Mail on your mobile. Anytime. Anywhere. Show me how.



--
Stephen W. Smith, MD
Faculty Emergency Physician
Hennepin County Medical Center
Associate Professor of Emergency Medicine
University of Minnesota School of Medicine

#12289 From: David Thomas <tazambo@...>
Date: Mon Jul 6, 2009 12:02 pm
Subject: Re: Chest pain job, 3 x arrests and an R on T
tazambo
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Hi Klaus,
 
Don't know what happenned to that link.
 
Go to my blog via the first link and click on the second image for an enlarged version.  My student cut it up and photocopied it but managed to cuit right near the final normal complex, but you can see that the first strip goes directly to the second.
 
Regards
Dave


From: Klaus Skrudland <lapsklaus@...>
To: ekg_club@yahoogroups.com
Sent: Monday, 6 July, 2009 5:23:13 PM
Subject: Re: [ekg_club] Chest pain job, 3 x arrests and an R on T

Dave-

I'd like to see the RonT but the last link is not working for me..


klaus

on, Jul 6, 2009 at 4:07 AM, David Thomas <tazambo@yahoo. com.au> wrote:



Hi Guys,

I had a good job yesterday.

My blog has the story and 3 EKG's for you to peruse.
http://tassieparame dic.blogspot. com/2009/ 07/good-chest- pain-job. html

Extra info, not on my blog post, is the patient was:
actually a Male
60 years old
Had lost 50Kg in last 2 years after gastric banding (down from 165kg)
has ? controlled Afib

The second image shows a nice R on T
http://1.bp. blogspot. com/_AuOignBm- 6A/SlFWKjoz38I/ AAAAAAAAACo/ Etc7D3bgz7w/ s1600-h/Vf_ Arrest_0907_ 1.jpg

Can anyone tell my why an LAD occlusion would involve I & aVL ?
I think I need to brush up on my coronary artery anatomy...

Regards
Dave


Access Yahoo!7 Mail on your mobile. Anytime. Anywhere. Show me how.



--
Mvh,
Klaus Nilsen Skrudland

http://www.lapsklau s.com
http://ecgblog. com
+ 47 99 38 67 55


Access Yahoo!7 Mail on your mobile. Anytime. Anywhere. Show me how.

#12288 From: "jesse12848" <jesse12848@...>
Date: Mon Jul 6, 2009 12:02 pm
Subject: Re: Rare ectopic rhythm
jesse12848
Offline Offline
Send Email Send Email
 
--- In ekg_club@yahoogroups.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@yahoogroups.com <ekg_club%40yahoogroups.com>, "jesse12848"
> > <jesse12848@> wrote:
> > >
> > > --- In ekg_club@yahoogroups.com <ekg_club%40yahoogroups.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@yahoogroups.com <ekg_club%40yahoogroups.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@yahoogroups.com
<ekg_club%40yahoogroups.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.lapsklaus.com
> http://ecgblog.com
> + 47 99 38 67 55
>
Paul- Would it be too simple to call this rhythm a 2nd degree type I AV
blockade? V1 appears to show a gradual lengthening of the P-R interval until,
after the third beat, a QRS is dropped. Also, am I seeing U waves in L3?

#12287 From: Klaus Skrudland <lapsklaus@...>
Date: Mon Jul 6, 2009 9:16 am
Subject: Re: Re: Rare ectopic rhythm
lapsklaus
Offline Offline
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Gene, et al, here are the attachments again, now hosted on my own server, so everyone should be able to see them:

http://www.lapsklaus.com/ekg/EKG-scanas/atrial_ectopic_a.jpg
http://www.lapsklaus.com/ekg/EKG-scanas/atrial_ectopic_b.jpg


Also: This is what I wrote in the first post, explaining my problem that I need help with:

"
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


On Mon, Jul 6, 2009 at 9:53 AM, <wegandy1938@...> wrote:


Would somebody please send the strip to me. For some reason it wasn't attached or in the body of any of the emails.

Gene



**************
Looking for love this summer? Find it now on AOL Personals.




--
Mvh,
Klaus Nilsen Skrudland

http://www.lapsklaus.com
http://ecgblog.com
+ 47 99 38 67 55

#12286 From: wegandy1938@...
Date: Mon Jul 6, 2009 3:53 am
Subject: Re: Re: Rare ectopic rhythm
wegandy
Offline Offline
Send Email Send Email
 
Would somebody please send the strip to me. For some reason it wasn't attached or in the body of any of the emails.

Gene



**************
Looking for love this summer? Find it now on AOL Personals.

#12285 From: Klaus Skrudland <lapsklaus@...>
Date: Mon Jul 6, 2009 7:23 am
Subject: Re: Chest pain job, 3 x arrests and an R on T
lapsklaus
Offline Offline
Send Email Send Email
 
Dave-

I'd like to see the RonT but the last link is not working for me..


klaus

on, Jul 6, 2009 at 4:07 AM, David Thomas <tazambo@...> wrote:


Hi Guys,

I had a good job yesterday.

My blog has the story and 3 EKG's for you to peruse.
http://tassieparamedic.blogspot.com/2009/07/good-chest-pain-job.html

Extra info, not on my blog post, is the patient was:
actually a Male
60 years old
Had lost 50Kg in last 2 years after gastric banding (down from 165kg)
has ? controlled Afib

The second image shows a nice R on T
http://1.bp.blogspot.com/_AuOignBm-6A/SlFWKjoz38I/AAAAAAAAACo/Etc7D3bgz7w/s1600-h/Vf_Arrest_0907_1.jpg

Can anyone tell my why an LAD occlusion would involve I & aVL ?
I think I need to brush up on my coronary artery anatomy...

Regards
Dave


Access Yahoo!7 Mail on your mobile. Anytime. Anywhere. Show me how.



--
Mvh,
Klaus Nilsen Skrudland

http://www.lapsklaus.com
http://ecgblog.com
+ 47 99 38 67 55

#12284 From: Klaus Skrudland <lapsklaus@...>
Date: Mon Jul 6, 2009 7:21 am
Subject: Re: Re: Rare ectopic rhythm
lapsklaus
Offline Offline
Send Email Send Email
 
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@yahoogroups.com, "jesse12848" <jesse12848@...> wrote:
>
> --- In ekg_club@yahoogroups.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@yahoogroups.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@yahoogroups.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.lapsklaus.com
http://ecgblog.com
+ 47 99 38 67 55

2 of 2 Photo(s)

#12283 From: David Thomas <tazambo@...>
Date: Mon Jul 6, 2009 2:07 am
Subject: Chest pain job, 3 x arrests and an R on T
tazambo
Offline Offline
Send Email Send Email
 
Hi Guys,

I had a good job yesterday.

My blog has the story and 3 EKG's for you to peruse.
http://tassieparamedic.blogspot.com/2009/07/good-chest-pain-job.html

Extra info, not on my blog post, is the patient was:
actually a Male
60 years old
Had lost 50Kg in last 2 years after gastric banding (down from 165kg)
has ? controlled Afib

The second image shows a nice R on T
http://1.bp.blogspot.com/_AuOignBm-6A/SlFWKjoz38I/AAAAAAAAACo/Etc7D3bgz7w/s1600-h/Vf_Arrest_0907_1.jpg

Can anyone tell my why an LAD occlusion would involve I & aVL ?
I think I need to brush up on my coronary artery anatomy...

Regards
Dave


Access Yahoo!7 Mail on your mobile. Anytime. Anywhere. Show me how.

#12282 From: "jesse12848" <jesse12848@...>
Date: Mon Jul 6, 2009 12:29 am
Subject: Re: Rare ectopic rhythm
jesse12848
Offline Offline
Send Email Send Email
 
--- In ekg_club@yahoogroups.com, "jesse12848" <jesse12848@...> wrote:
>
> --- In ekg_club@yahoogroups.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@yahoogroups.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@yahoogroups.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.

#12281 From: "jesse12848" <jesse12848@...>
Date: Mon Jul 6, 2009 12:17 am
Subject: Re: Rare ectopic rhythm
jesse12848
Offline Offline
Send Email Send Email
 
--- In ekg_club@yahoogroups.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@yahoogroups.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@yahoogroups.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.

#12280 From: PMATERAMD@...
Date: Mon Jul 6, 2009 12:17 am
Subject: Re: Re: Rare ectopic rhythm
pmateramd
Offline Offline
Send Email Send Email
 
5th out of 41 overall. Did better a few weeks ago especially on long range high power rifle with a 97/100 5x with iron sights. Reading EKGs is like competitive shooting. EKG interpretation requires taking into account age, sex, weight, lead placement, prior history ... Target shooting requires taking into account temp, humidity, wind direction, prior shot placement, etc. BTW can anyone tell me how to recover emails that I read on my blackberry first then when I go to find them on laptop they are gone. I didn't erase them from blackberry just read them. Or is this another aol issue. Thanks. Paul (PMMD)

Sent from my Verizon Wireless BlackBerry


From: Nikiah Nudell
Date: Sat, 4 Jul 2009 18:41:47 -0700
To: <ekg_club@yahoogroups.com>
Subject: Re: [ekg_club] Re: Rare ectopic rhythm

I guess you didn't lose!
Nick

On 07/04/2009, PMATERAMD@aol.com <PMATERAMD@aol.com> wrote:
> On my way home from a 3 gun (pistol rifle shotgun) combat competition, it is
> the 4th of July after all, on my blackberry now, I will take a look on my
> laptop asap
> Paul
> PMMD
> Sent from my Verizon Wireless BlackBerry
>
> -----Original Message-----
> From: Klaus Skrudland <lapsklaus@gmail.com>
>
> Date: Sat, 4 Jul 2009 21:21:33
> To: <ekg_club@yahoogroups.com>
> Subject: [ekg_club] Re: Rare ectopic rhythm
>
>
> Really, no comments?? Hmm.
>
>
>
>
>
>
> On Wed, Jul 1, 2009 at 12:56 PM, Klaus Skrudland
> <lapsklaus@gmail.com>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
>>
>
>
>
> --
> Mvh,
> Klaus Nilsen Skrudland
>
> http://www.lapsklaus.com
> http://ecgblog.com
> + 47 99 38 67 55
>
>

--
Sent from my mobile device


#12279 From: suthaporn lumlertgul <ltongtaa@...>
Date: Sun Jul 5, 2009 7:25 pm
Subject: Re: Re: Rare ectopic rhythm
ltongtaa
Offline Offline
Send Email Send Email
 
To me what I can crack is it's a indepedent ventricle and atrial rhythm.
Somehow the morphology of P wave look like it come from sinus. (They're all the same morphology, it's not a narrow peak tip point which would be that way if come from atrial tissue and should be different a bit)
The ventricle beat look like it come from junctional.. I mean it look a bit different form each other not all the same morphology so it may not come form automaticity origin.
Well that 's all for now. What do you guys think?

--- On Sun, 7/5/09, thatsuthant <thatsuthant@...> wrote:

From: thatsuthant <thatsuthant@...>
Subject: [ekg_club] Re: Rare ectopic rhythm
To: ekg_club@yahoogroups.com
Date: Sunday, July 5, 2009, 3:16 AM

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, 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
>


#12278 From: Nikiah Nudell <medicnick@...>
Date: Sun Jul 5, 2009 7:06 pm
Subject: Re: Re: Rare ectopic rhythm
mtparamednick
Offline Offline
Send Email Send Email
 
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@yahoogroups.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@yahoogroups.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.



#12277 From: Nikiah Nudell <medicnick@...>
Date: Sun Jul 5, 2009 6:14 pm
Subject: Re: Re: Rare ectopic rhythm
mtparamednick
Offline Offline
Send Email Send Email
 
Welcome to the club... please post your name so we know who were responding to.
 
There are a couple of things to look at. The width of the QRS, presence of or disassociation with Pwaves, patterns in the complexes, etc.
 
First, look for Pwaves. Are they present? Are they associated with QRS? Do they precede the QRS?
Next, are the QRS complexes changing shape or width? Are they regular or irregular?
 
It is a commonly thought incorrect legend that "compensatory pauses" are associated only with PVCs. We've seen and posted many examples here of compensatory pauses following PACs or other non-ventricular arrythmias.

Cheers,
Nick


 
On Sun, Jul 5, 2009 at 03:16, 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@yahoogroups.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
>



#12276 From: "jesse12848" <jesse12848@...>
Date: Sun Jul 5, 2009 6:12 pm
Subject: Re: Rare ectopic rhythm
jesse12848
Offline Offline
Send Email Send Email
 
--- In ekg_club@yahoogroups.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@yahoogroups.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.

#12275 From: "jesse12848" <jesse12848@...>
Date: Sun Jul 5, 2009 6:02 pm
Subject: Re: Rare ectopic rhythm
jesse12848
Offline Offline
Send Email Send Email
 
--- In ekg_club@yahoogroups.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@yahoogroups.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
> >
>
aa

#12274 From: "thatsuthant" <thatsuthant@...>
Date: Sun Jul 5, 2009 10:16 am
Subject: Re: Rare ectopic rhythm
thatsuthant
Offline Offline
Send Email Send Email
 
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@yahoogroups.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
>

#12273 From: Nikiah Nudell <medicnick@...>
Date: Sun Jul 5, 2009 1:41 am
Subject: Re: Re: Rare ectopic rhythm
mtparamednick
Offline Offline
Send Email Send Email
 
I guess you didn't lose!
Nick


On 07/04/2009, PMATERAMD@... <PMATERAMD@...> wrote:
> On my way home from a 3 gun (pistol rifle shotgun) combat competition, it is
> the 4th of July after all, on my blackberry now, I will take a look on my
> laptop asap
> Paul
> PMMD
> Sent from my Verizon Wireless BlackBerry
>
> -----Original Message-----
> From: Klaus Skrudland <lapsklaus@...>
>
> Date: Sat, 4 Jul 2009 21:21:33
> To: <ekg_club@yahoogroups.com>
> Subject: [ekg_club] Re: Rare ectopic rhythm
>
>
> Really, no comments?? Hmm.
>
>
>
>
>
>
> On Wed, Jul 1, 2009 at 12:56 PM, 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
>>
>
>
>
> --
> Mvh,
> Klaus Nilsen Skrudland
>
> http://www.lapsklaus.com
> http://ecgblog.com
> + 47 99 38 67 55
>
>

--
Sent from my mobile device

#12272 From: Klaus Skrudland <lapsklaus@...>
Date: Sun Jul 5, 2009 1:26 am
Subject: rhythm simulator
lapsklaus
Offline Offline
Send Email Send Email
 
Everyone - please read the info from Billy Hurd at Pace Symposia. Check out the rhythm simulator, I think it looks really good and could become a great tool for both beginners and those who need to brush up or just wants to play around with it.
 
Billy says: "I'm glad you like the simulator.  Feel free to show it to your colleagues.  I have a new website up now at http://www.ecgsimulator.net.  Please tell anyone who asks about it to visit our website to download the trial version or see a live demo."
 
Also, I´ve been asked to help with the info on each rhythm., but I´d love to hear your opinions and ideas. Under the rhythm strip there will be an info sheet/cheat sheet that provides information on each arrhythmia. IWhat do you think about the following layout:
 
Name and abbreviations (NSR, EAT, AF, VT)
Characteristics/measurements like PR, QRS and QTc times, etc.
Description/morphology, how to recognize each rhythm. Just a bried explanation.
Interpretation, what the rhythm means. Briefly, just a couple of sentences.
In depth, a couple of sentences describing the "science" behind the arrhythmia.
 
 
- klaus
Comments?! Other ideas!?
 
 
 

#12271 From: Klaus Skrudland <lapsklaus@...>
Date: Sun Jul 5, 2009 12:39 am
Subject: Re: Re: Rare ectopic rhythm
lapsklaus
Offline Offline
Send Email Send Email
 
Great!
 
I sat down yesterday and tried to make a ladderdiagram (yes I´m a nerd) to understand the AV block here, but I just can´t hack it.
 

 
On Sat, Jul 4, 2009 at 10:40 PM, <PMATERAMD@...> wrote:


On my way home from a 3 gun (pistol rifle shotgun) combat competition, it is the 4th of July after all, on my blackberry now, I will take a look on my laptop asap
Paul
PMMD

Sent from my Verizon Wireless BlackBerry


From: Klaus Skrudland
Date: Sat, 4 Jul 2009 21:21:33 +0200
To: <ekg_club@yahoogroups.com>
Subject: [ekg_club] Re: Rare ectopic rhythm

Really, no comments?? Hmm.
 
 
 


 
On Wed, Jul 1, 2009 at 12:56 PM, 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



--
Mvh,
Klaus Nilsen Skrudland

http://www.lapsklaus.com
http://ecgblog.com
+ 47 99 38 67 55




--
Mvh,
Klaus Nilsen Skrudland

http://www.lapsklaus.com
http://ecgblog.com
+ 47 99 38 67 55

#12270 From: PMATERAMD@...
Date: Sat Jul 4, 2009 8:40 pm
Subject: Re: Re: Rare ectopic rhythm
pmateramd
Offline Offline
Send Email Send Email
 
On my way home from a 3 gun (pistol rifle shotgun) combat competition, it is the 4th of July after all, on my blackberry now, I will take a look on my laptop asap
Paul
PMMD

Sent from my Verizon Wireless BlackBerry


From: Klaus Skrudland
Date: Sat, 4 Jul 2009 21:21:33 +0200
To: <ekg_club@yahoogroups.com>
Subject: [ekg_club] Re: Rare ectopic rhythm

Really, no comments?? Hmm.
 
 
 


 
On Wed, Jul 1, 2009 at 12:56 PM, Klaus Skrudland <lapsklaus@gmail.com> 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



--
Mvh,
Klaus Nilsen Skrudland

http://www.lapsklaus.com
http://ecgblog.com
+ 47 99 38 67 55


#12269 From: Klaus Skrudland <lapsklaus@...>
Date: Sat Jul 4, 2009 7:29 pm
Subject: Pace symposia/rhythm simulator
lapsklaus
Offline Offline
Send Email Send Email
 
Hi, all!
 
I´m forwarding something from Billy Hurd, a programmer for Pace Symposia. I think this might be of interest for many of you. Pace symposia is working on an ekg rhythm simulator. I´ve tested the beta version and it looks awesome. Rhythms are generated in real time, with very realistic morphology. He asked me for feedback, and I thought I´d ask you guys. If anyone wants to check it out and give feedback, I´ll forward it to him. I´m not sure if the trial version is a full version, but you´ll get an idea of it.
 
Personally, from what I´ve seen so far, it looks great, but I´m missing some essential arrhythmias, such as polymorphic VT, Vflutter, higher ratios of AV blocks, such as 3:2 and 4:3.
 
Check it out here:
>Comment:
>Just stumbled across your blog while trying to increase my understanding of ECGs.  I am a software developer, not a medical >professional, but I am currently designing a <a href="http://www.pacesymposia.com/ecgsimulator/" rel="nofollow">Software ECG >Simulator</a>.  Thank you for the wonderful information you provide on your site.  I would love to get feedback from someone of >your expertise.  Would you mind taking a look at our simulator?

>Regards,

>Billy


#12268 From: Klaus Skrudland <lapsklaus@...>
Date: Sat Jul 4, 2009 7:21 pm
Subject: Re: Rare ectopic rhythm
lapsklaus
Offline Offline
Send Email Send Email
 
Really, no comments?? Hmm.
 
 
 


 
On Wed, Jul 1, 2009 at 12:56 PM, 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



--
Mvh,
Klaus Nilsen Skrudland

http://www.lapsklaus.com
http://ecgblog.com
+ 47 99 38 67 55

#12267 From: Klaus Skrudland <lapsklaus@...>
Date: Wed Jul 1, 2009 1:04 pm
Subject: Re: Re: Interesting find
lapsklaus
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Great case. Thanks a lot for sharing. Looking forward to seeing the rest of the rhythms stored on the lp12! :-)
 

 
On Wed, Jul 1, 2009 at 1:06 PM, Nikiah Nudell <medicnick@...> wrote:


Hey Brant,
Glad to see you posting the details! It is a funny story with a good outcome that we can all learn from. I hope you'll find the the EKGs, especially after all the LP12 issues we had the next day.
 
Take care,
Nick
 


 
On Mon, Jun 29, 2009 at 11:33, rwj3032 <brm412@...> wrote:


Not to be a tease, but we do have more rhythms to share about this patient, however they are locked inside the LP12 until I get back to work tomorrow. This patient presented as a STEMI in V4,V5 and we initiated our treatment with ASA and Nitro SL. My partner stepped outside to consult our medical control and the BLS crew was in the hallway preparing the stretcher. Almost immediately post Nitro SL I noticed the Poly VT. Im thankful I had the presence of mind to print it. (Klaus and Nick, sit down before you read this next part) Regret that I didn't catch a 12ld (considering the leads were in place from evaluating the STEMI) I dug out the Defib pads, placed the first, rolled the patient to place the second when he asks "What was that?" The arrhythmia resolved quickly and without any (intentional) interventions and we proceeded to medical consult receiving the orders for Mag 2grams and Amiodarone 150mg both over 10 min rpt NTG. En route to the ED the patient reported his discomfort has decreased but complained of nausea/vomiting x1. The follow up from the ED (an emergent cathlab only)stated the ST elevations were not significant enough for emergent cath, so the patient was transfered to the partnering elective cath facility. No follow up from that facility, but we could give them a call tomorrow.
Brant





--
Mvh,
Klaus Nilsen Skrudland

http://www.lapsklaus.com
http://ecgblog.com
+ 47 99 38 67 55

#12266 From: Nikiah Nudell <medicnick@...>
Date: Wed Jul 1, 2009 11:06 am
Subject: Re: Re: Interesting find
mtparamednick
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Send Email Send Email
 
Hey Brant,
Glad to see you posting the details! It is a funny story with a good outcome that we can all learn from. I hope you'll find the the EKGs, especially after all the LP12 issues we had the next day.
 
Take care,
Nick
 


 
On Mon, Jun 29, 2009 at 11:33, rwj3032 <brm412@...> wrote:


Not to be a tease, but we do have more rhythms to share about this patient, however they are locked inside the LP12 until I get back to work tomorrow. This patient presented as a STEMI in V4,V5 and we initiated our treatment with ASA and Nitro SL. My partner stepped outside to consult our medical control and the BLS crew was in the hallway preparing the stretcher. Almost immediately post Nitro SL I noticed the Poly VT. Im thankful I had the presence of mind to print it. (Klaus and Nick, sit down before you read this next part) Regret that I didn't catch a 12ld (considering the leads were in place from evaluating the STEMI) I dug out the Defib pads, placed the first, rolled the patient to place the second when he asks "What was that?" The arrhythmia resolved quickly and without any (intentional) interventions and we proceeded to medical consult receiving the orders for Mag 2grams and Amiodarone 150mg both over 10 min rpt NTG. En route to the ED the patient reported his discomfort has decreased but complained of nausea/vomiting x1. The follow up from the ED (an emergent cathlab only)stated the ST elevations were not significant enough for emergent cath, so the patient was transfered to the partnering elective cath facility. No follow up from that facility, but we could give them a call tomorrow.
Brant



#12265 From: Klaus Skrudland <lapsklaus@...>
Date: Wed Jul 1, 2009 10:56 am
Subject: Rare ectopic rhythm
lapsklaus
Offline Offline
Send Email Send Email
 
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

2 of 2 Photo(s)


#12264 From: Nikiah Nudell <medicnick@...>
Date: Tue Jun 30, 2009 5:45 pm
Subject: Re: Hmmm
mtparamednick
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That sounds plausible... What would capnography look like in that
situation? The high BP concerns me still...
Nick


On 06/30/2009, wegandy1938@... <wegandy1938@...> wrote:
> There's no S1Q3T3 pattern or anything else to suggest pulmonary embolism
> that I can see.   He's tacky, so there's something happening but I agree
> with
> Paul that it's probably not cardiac.   I have seen the strip, and it's sinus
> with a LBBB and occasional PACs and one PVC.   QRS axis is 60 odd.   There
> is one interesting thing.   In leads I, II, III, and aVF the T waves are
> sometimes properly discordant but at other times not.   And it's not the
> PACs
> that are different.   There are occasional sinus beats with a concordant T
> wave.   the Qrs looks the same.   Now I don't have a clue what this means.
> I
> also don't see how it reflects anything that's causing the dyspnea.
>
> Could this guy have just produced a bunch of mucus and not been coughing
> because of the soreness from the hernia and there was a mucus plug or
> something?   The fact that he got better suggests that something "moved" or
> crawled
> back into its cave.   But the greatly diminished left side lung sounds
> trouble me.   Pneumo?
>
> All the time his CO2 was about 45 or so with a nice waveform.
>
> Also I don't see the correlation with the BP unless it was pure
> catecholamine related due to his dyspnea.
>
> Anxiety attack?
>
> I'm probably full of it, but that's all I can come up with.   Somebody HELP
> ME!   LOL.
>
> Gene G.
> In a message dated 6/29/09 7:57:53 AM, PMATERAMD@... writes:
>
>
>>
>>
>>
>> hi i cant see ecg either i will go by case presentation and vitals and
>> descriptions of the ecg by others,,, in general he is 48h sp surgery and
>> he
>> has plenty of bp therefore a direct cardiac cause of his sob is unlikey,
>> he
>> is sp surgery so pe is possible, he is struggling to maintain his O2
>> delivery with low pulse ox and reversible with O2 and peep point to a
>> pulmonary
>> parenchyma issue, pe, peumonitis, pneumonia, pneumo, pulmonary edema,
>> etc.,
>> he has a pulse and has excellent bp then this is unlikely a primary
>> cardiac
>> output issue and I would seriously resist any attempt at rate control with
>>
>> any med as this is likely to make the sob worse (ie reduce the already
>> reduced pulmonary perfusion) ie we dont try to fix what is not broke,
>>  any jvd filling from below, pulsus paradoxicus, sub q emphysema, etc
>>
>>  Paul
>>
>>  Paul A. Matera, MD, D-EM, D-IM, EMTP
>> Clinical Associate Professor - George Washington University, D.C.
>> Director Emeritus - Critical Care Units, Providence Hospital, D.C.
>>
>>
>>  In a message dated 6/28/2009 5:14:16 P.M. Eastern Daylight Time,
>> medicnick@... a messag
>>
>>  [Attachment(s) from Nikiah Nudell included below]
>>
>>
>> Second attempt for JD.
>> Thanks,
>> Nick
>>
>> ---------- Forwarded message ----------
>> From: Nikiah Nudell <medicnick@...>
>> Date: Sat, 27 Jun 2009 23:49:10 -0400
>> Subject: Hmmm
>> To: ekg_club@yahoogroupekg_c
>>
>> Attached you'll find a case of a 67 year old male two days post open
>> abdominal hernia repair. He experienced 45 minutes of sudden onset SOB
>> while
>> resting at home. Denies HA, CP, abd pain, or any symptom other than
>> difficulty breathing.
>>
>> His BP is 220/140, BGL 210, RR 40s, skin pale, warm/hot, moist. Airway is
>> patent although retractions are visible. Left lung sounds very diminished,
>> right side intially with wheezing changing to coarse rhonchi during care.
>>
>> 12lead, rhythm strip and EtCO2 attached. Past medical history of AAA with
>> aortic valve replacement & HTN reported. Patient takes coumadin, flomax,
>> lisinopril, and cardizem. Pt allergic to ASA and PCN.
>>
>> What say ye?
>>
>> Cheers,
>> Nick
>>
>> --
>> Sent from my mobile device
>>
>>
>>
>
> Make your summer sizzle with fast and easy recipes for the grill.
>
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>
>
>
>
>
>
>
> **************
> Make your summer sizzle with fast and easy recipes for the
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