afib vs sinus arrhythmia
First Glance:
From across the room it looks like supraventricular rhythm that might be afib, or it might be sinus arrhythmia.
Discussion:
You see this kind of rhythm in afib, but the fact that it looks like it speeds and slows somewhat cyclically might suggest that this is actually sinus arrhythmia. The first step is searching for P waves:
Do you think these are P waves?
The deflections marked in orange might be P waves, but they’re not the same each time, and the intervals are not the same, and sometime there are none before the QRS. Maybe these are sinus P’s, plus some PACs, or maybe there is a wandering pacemaker. Or maybe these are course fibrillatory baseline changes as seen in atrial fibrillation.
To crack this case we could pore over some other leads (I’d probably start by gaining this up a bit, and then by looking at the chest lead). Or- what about the lower trace. It’s a CVP tracing, and theoretically we should see A waves that coincide with the deflections we think might be P’s.
Admittedly, it’s hard for me to be sure what is the C and V waves, but there is one thing I do feel good about: I don’t see anything that looks like an A wave where it would expected- that is a little behind the P wave, but just before the QRS. This would be easier if we changed the gain on the CVP tracing. Given that this patient’s CVP is bouncing around between 2 and 5mmHg, there is no reason not to gain down to 10 or 15mmHg which would give us a clear tracing with better waveforms.
All told, I’m sticking with afib.
The complexes are borderline wide with predominantly negative forces in lead II, which is abnormal, suggestive of LAD- maybe LAFB.
Final Impression?
Atrial fibrillation @ ~90 bpm, suspicious for axis change and aberrancy.
Management implications:
12L to evaluate for ischemia/infarction and aberrancy. You could confirm the rhythm definitively with a much longer strip easily, or just looking at different leads most likely.
The Take-home Point:
The atrial activity solves most rhythm identification problems. You can pick up on atrial activity not just electrically, but mechanically in the CVP waveform.
Two star strip. The meat and potatoes.