sinus rhythm with low voltage
First Glance:
From across the room it looks a regular narrow complex rhythm.
Discussion:
Lead II is jacked up to 200% gain and we are still only seeing a 4mm QRS. This is clearly a low voltage strip, and if I saw it on a 12L it would make me wonder whether there were low voltages across the limb leads. However, this is a tele strip and the voltages are unpredictable, especially considering the non-standard placements of electrodes and patient positioning compared to 12L EKG. It is always possible that this patient has an unusual axis and their lead II is almost isoelectric, whereas the rest of the leads might show normal voltages.
Note that lead placement issue is less of an issue here, as it is lead II. You could put the limb leads anywhere you wanted on the limbs and the complexes would change very little in terms of morphology. It could be nothing, or maybe this patient has something else going on to reduce the complex amplitude. Things like infiltrative diseases, pneumothoraces, tamponade, and morbid obesity can make for tiny voltages.
Regardless, our capable ICU team has increased the gain to see the waves. There are regular P waves and inverted T waves.
What about the lower trace? Pt isn’t breathing? Maybe.
Or- maybe the leads need to be moved more centrally to better pick up on respiratory impedance changes in the chest wall.
Final Impression?
Normal sinus rhythm @ ~80 bpm with T wave inversion.
Management implications:
12L to evaluate for low voltage/ischemia. Consider CXR or thoracic/cardiac ultrasound if there is low voltage across the board, but note that low voltage on tele is often positional or artifactual.
The Take-home Point:
This strip is straightforward. You feel relieved to see sinus rhythm. So here’s a pop quiz:
If you see this strip and someone says there is no pulse, what do you do?
Check the pulse. And if you feel no pulse?
Start compressions. You could have a lovely looking strip with even less going on than this one and still have a pulseless patient who needs a little exogenous pumping.
One star strip. Students should identify the rhythm correctly.