SVT, 140 – 190 bpm
First Glance:
From across the room it looks like a fast and irregular narrow-complex tachycardia.
Discussion:
Deja-vu, right? Different patient, but same quandrary. We have a rapid narrow-complex rhythm but we can’t pick it apart with this strip. It starts off around 150-160, and could be sinus tach. That first dozen beats look pretty regular, possibly with a positive P wave slapped onto the end of the T wave. Then there are some messy parts which could be named arrhythmias (AF, MAT, etc), or just some supraventricular ectopy. Late in the strip we see this QRS complex:
Is that a PVC? I’d argue no- it has similar morphology to the rest of the strip, but is wider and taller. It may be an aberrant beat, for instance if one of the parts of one of the bundles wasn’t completely repolarized yet for that beat (a temporary minor fascicular or bundle branch block) or a fusion beat.
Here’s another strip from the same patient:
Pretty much the same. The rate is ~190 for the second half of the strip. There is one PVC at beat 5. If that other weird beat was a PVC than this one (with different morphology/axis) would mean there are polymorphic PVCs. No firm prognostic significance, but it suggest a more irritable myocardium than monomorphic PVCs.
Check out that respiratory tracing. Breaths every ~7 large boxes. That is 7 x 0.2s = 1.5s per breath = 40 breaths per minute.
Final Impression?
Irregular SVT. Probably sinus tach converting to afib. Hard to say though.
Management implications:
Per strip 8. Nothing particularly specific here.
The Take-home Point:
No firm electrophysiologic diagnosis, but a tachycardia at 190, a RR of 40, and an SpO2 93% should get your attention!
Two star strip. The meat and potatoes.