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<\/a><\/p>\nFirst Glance:<\/strong><\/p>\n From across the room it looks like a supraventricular rhythm with grouped beats of three.<\/p>\n Discussion:<\/strong><\/p>\n Grouped beats could mean all kinds of things. A second degree block, regular premature ectopy (bigeminy, trigeminy, etc), various supraventricular rhythms with variable blocks, and then a few really unusual entities. This particular strip is tricky- partly because it is tricky, and partly because it has (per usual) diminutive voltages which makes analysis of the atrial activity tricky. What a shame that this lead is gained down to 30%.<\/p>\n Did you see any regularity in the baseline? Your best bet of discovering something subtle is looking at the flat sections of baseline before the first QRS of a group (where the leftover T’s and U’s from the last group will no longer be present).<\/p>\n Here’s what I see: There are regular negative deflections (green triangles) in the baseline. The rate is around 300. This could be atrial flutter, with the rest of the F waves overrun by the QRS’s and the T waves that follow those QRS’s. In that case, this would be aflutter with a variable block. Usually it’s 2:1, but then occasionally it jumps up to 4:1 every third beat. This is actually a common pattern in my experience, although usually it is alternating 2:1 -> 4:1 -> 2:1 -> etc.<\/p>\n This is where the hidden F waves are: They are hard to pick out because they are slathered on top of the T waves and QRS’s, but the correlation seems consistent and the interval between the preceding F wave and the first QRS of each group is very regular.<\/p>\n Here’s more strip: Do you see it? It’s hard to be 100% sure from this strip. If you could see longer pauses you might seal the diagnosis, so you could try some vagal maneuvers to try to get some transient 6:1 or longer block, or you could give adenosine, or you could stop messing around, gain the strip up, and get a 12L!<\/p>\n The P waves are probably not ectopic atrial tachycardia as they are the fast side for that rhythm. It’s still a possiblity though, but flutter just fits better here.<\/p>\n What’s the heartrate? Count 3 second blocks. I count 11 beats in 2 blocks which makes about 110 a minute– for once the monitor and I agree.<\/p>\n Final Impression?<\/strong><\/p>\n Atrial flutter with 2:1 -> 2:1 -> 4:1 variable block, ventricular rate is 110.<\/p>\n Management implications:<\/strong><\/p>\n Increase the gain to see the P waves. Confirm with 12L. A lewis lead could clarify atrial activity if still in doubt.<\/p>\n \u00a0The Take-home Point:<\/strong><\/p>\n Atrial flutter, in my experience, is the great imitator. A classic flutter strip might be easy, but if you have a 2:1 block (common) or the F waves are not visible or obvious (common) or the block is variable than it can look like all manner of supraventricular rhythms, and can be irregularly irregular.<\/p>\n I have read somewhere that atrial flutter seems to be predisposed to even-numbered blocks (2:1, 4:1) although not every expert agrees. In my experience aflutter with variable block tends to be regularly irregular (as we see here, or with the alternating 2:1 -> 4:1 pattern mentioned earlier), but often there are odd-numbered and variably variable blocks which can look just like afib if the F waves aren’t obvious.<\/p>\n Of note: if you are<\/em> seeing aflutter with a high-grade block (think 4:1 or above), consider dig toxicity. Dig is especially likely to cause flutter with a high-grade block because it both predisposes to supraventricular ectopy\/flutter, and<\/em> slows the AV node.<\/p>\n It’s worth keeping atrial flutter on the differential because it’s treatment and prognosis is significantly different from most of the other supraventricular tachycardias.<\/p>\n <\/p>\n <\/p>\n <\/p>\n atrial flutter First Glance: From across the room it looks like a supraventricular rhythm with grouped beats of three. Discussion: Grouped beats could mean all kinds of things. A second degree block, regular premature ectopy (bigeminy, trigeminy, etc), various supraventricular rhythms with variable blocks, and then a few really unusual entities. This particular strip is …read more<\/a><\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[2],"tags":[5],"class_list":["post-354","post","type-post","status-publish","format-standard","hentry","category-cases","tag-3star"],"_links":{"self":[{"href":"https:\/\/www.electricant.net\/ekg\/wp-json\/wp\/v2\/posts\/354","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.electricant.net\/ekg\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.electricant.net\/ekg\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.electricant.net\/ekg\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.electricant.net\/ekg\/wp-json\/wp\/v2\/comments?post=354"}],"version-history":[{"count":12,"href":"https:\/\/www.electricant.net\/ekg\/wp-json\/wp\/v2\/posts\/354\/revisions"}],"predecessor-version":[{"id":357,"href":"https:\/\/www.electricant.net\/ekg\/wp-json\/wp\/v2\/posts\/354\/revisions\/357"}],"wp:attachment":[{"href":"https:\/\/www.electricant.net\/ekg\/wp-json\/wp\/v2\/media?parent=354"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.electricant.net\/ekg\/wp-json\/wp\/v2\/categories?post=354"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.electricant.net\/ekg\/wp-json\/wp\/v2\/tags?post=354"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}
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\n<\/a><\/p>\n\u00a0<\/em>Three star strip. Devious stuff.<\/em><\/p>\n—> see the next strip<\/a><\/h1>\n","protected":false},"excerpt":{"rendered":"