sinus bradycardia
NOTE. THIS STRIP HAS NOT BEEN REVIEWED.
First Glance:
From across the room it looks sinus rhythm on the slow side.
Discussion:
It looks like sinus rhythm, and we won’t go into why. You should be hammering those home right now. The rate is around 50 bpm, which most anyone would call bradycardic.
The lower trace is an arterial line, with a trace without significant notches, and what to me looks like a slow ramp up. I wonder if this is aortic stenosis.
Now look at the gain. We are at 25% in lead II here. So those QRS’s would actually be about 8 x 4 = 32mm tall in lead II at standard gain of 10mm/mV. Voltage criteria for the limb leads is 14mm in lead I and 11mm in AVL, so while I am unfamiliar with LVH criteria in lead II this is strongly suggestive of big LV forces (either LVH or acute left heart strain). The BP is only 106 systolic. Maybe this patient is in heart failure due to severe aortic stenosis? I’m just guessing.
Final Impression?
Sinus bradycardia ~ 50 bpm, suggestive of LVH.
Management implications:
Flipping through the leads would show you voltages in the other limb leads. A 12L would give you lateral leads where you could assess for LVH by standard voltage criteria and any repolarization abnormalities consistent with strain (inverted T waves in the lateral leads). A good physical exam might seal this diagnosis in some patients, and obviously an echo would get the definitive look at the valves and flow.
Flushing the A-line would confirm the waveform is not an artifact of air/clot dampening, etc.
The Take-home Point:
Use all your senses- not just EKG monitoring, but the other recorded inputs as well. Every monitoring modality can give you information, and if you put them together you can come up with good differentials for the process at hand.
One star strip. Students should identify the rhythm correctly.