afib with PVC
First Glance:
From across the room it looks like an irregular narrow-complex tachycardia.
Discussion:
This rhythm is irregularly-irregular, which once again spits afib into our head. Can’t help that. The baseline shows some waves but nothing that is remotely consistent, so this is likely afib after all. It could also be multifocal atrial tachycardia, as there are some P waves which have reasonable PR intervals, appear to show up more than once, etc, but with this strip we are unlikely to clinch that diagnosis.
The V lead shows a little bit of ST depression. We might check on that with a 12L.
The PVC is upright in II and the chest lead, which weakly suggests it originates high in the ventricle and the myocardium is depolarizing roughly downwards and leftwards.
Here’s another strip from the same patient:
Same stuff. What could we do to improve our view? Look at the voltage calibration. 5mm/mv. If we put that up to standard calibration (10mm/mv) we would have twice the amplitude and we might start picking out the waves better in the off-chance there was something interesting to look at.
Final Impression?
Likely afib with RVR @ ~120 bpm with one PVC. Can’t rule out other supraventricular rhythms such as MAT, etc.
Management implications:
Standard stuff. 12L to evaluate ST changes seen on monitor.
The Take-home Point:
Telemetry is mainly to monitor rhythms, not ischemic changes, so you might as well optimize the view for seeing arrhythmia. To that end, adjust your tele machine to a lead or two that show the atrial activity best, and increase the gain as much as possible without getting waves too large for the paper- or if necessary more.
It would be incredibly annoying if every 12L had those tweaks, but in telemetry we do not count millimeters of ST elevation. We do not measure P waves to evaluate for atrial enlargement. We just want a quick way to see what is going on, and all abnormalities can be evaluated by the 12L as necessary.
One star strip. Students should identify the rhythm correctly.